VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Warren
935 S Ox Road
Woodstock, VA 22664
(540) 459-2525

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Feb. 1, 2024

Complaint Related: Yes

Areas Reviewed:

Staffing and Supervision Resident Care and Related Services

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/1/2024, 9:30am-1:30pm The acknowledgement of inspection for was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/11/2024 regarding allegations in the area of staffing and supervision and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 17 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be founds on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with the applicable standards or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-A
Complaint related:	No
Description:	Based upon review of records and interviews, the facility has failed to ensure staff sufficient in numbers to provide services to attain and maintain the physical, mental and psychosocial well-being of each resident as determined by resident assessments and individualized service plans for the evening shift (2pm to 10pm) and the overnight shift (10pm to 6am). Evidence: 1. Interview with Collateral Contact 1 conducted on 2/1/2024 at approximately 10:00am revealed that the facility staff two direct care staff and one medication aide for every shift. 2. The staff scheduled for January 2024 documented that there are consistently tow direct care staff and one medication aide on the evening and overnight shifts. 3. According to ISPs, Residents 4, 5, 10 and 13 require mechanical help, physical assistance - human help with transferring. Resident 5 is transferred with a Hoyer lift that requires two people to perform the task. Resident 12 requires mechanical help, physical assistance-supervision with transferring. 4. Collateral Contact 2 interviewed on 2/1/2024 at approximately 1:00pm revealed that Resident 14 often receives assistance from family members with changing incontinence products. Collateral Contact 2 commented that "not enough staff" is the biggest area of concern. Collateral Contact 2 revealed that Resident 14 has been found sitting in wet incontinence products for what appears to have been a long period of time. According to Collateral Contact 2, staff have asked family members to help with changing Resident 14's incontinence products.
Plan of Correction:	Resident Wellness Director with support of Resident Care Director will ensure that there is sufficient staffing for the needs of the facility to maintain the physical, mental and psychosocial well-being of each resident. This will be done by reassessment of all current residents to capture those care levels accurately. Care Plans will be updated to reflect. Staffing will be adjusted with resident need. (Staffing was adjusted on the day of inspection) Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that all residents of assisted living facilities were assessed using the Uniform Assessment Instrument (UAI) at least annually for eight out of seventeen residents. Evidence: 1. Resident 2 last UAI was completed 12/22/2022 2. Resident 3 last UAI was competed 12/15/2022 3. Resident 5 last UAI was completed 12/7/2022 4. Resident 6 last UAI was completed 1/10/2023 5. Resident 7 last UAI was completed 1/19/2023 6. Resident 8 last UAI was completed 1/27/2023 7. Resident 14 last UAI was completed 12/15/2022 8. Resident 15 last UAI was completed 12/25/2022
Plan of Correction:	Resident Wellness Director with the support of the Resident Care Director will ensure that all residents have current UAI (Uniform Assessment Instrument) upon admission and is updated yearly or upon changes. An audit of all current residents will be completed to ensure compliance and accuracy. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that the comprehensive individualized service plans were completed within 30 days after admission for two of seventeen residents. Evidence: 1. Resident 16 was admitted on 11/16/2023. No ISP was found in her record. 2. Resident 17 was admitted on 11/28/2023. No ISP was found in her record.
Plan of Correction:	Resident Wellness Director with the support of the Resident Care Director will ensure that all residents will have an Individualized Service Plan completed upon admission and a comprehensive Plan will be developed within 30 days of move in. A review of all charts will be conducted to ensure that all residents have a current up to date Individualized Service Plan reflecting current needs Executive Director will provide oversight to ensure compliance
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that the individualized service plans (ISPs) were updated once every 12 months for nine out of seventeen residents. Evidence: 1. Resident 2 last ISP was updated 3/22/2022 2. Resident 3 last ISP was updated 3/15/2022 3. Resident 5 last ISP was updated 3/7/2022 4. Resident 6 last ISP was updated 4/11/2022 5. Resident 7 last ISP was updated 4/16/2022 6. Resident 8 last ISP was updated 4/30/2022 7. Resident 9 last ISP was updated 4/30/2022 8. Resident 14 last ISP was updated 12/15/2022 9. Resident 15 last ISP was updated 1/4/2023
Plan of Correction:	Resident Wellness Director with assistance of the Resident Care Director or designee will review all current ISP?s for accuracy and will ensure that all ISP?s are updated yearly and upon changes. Executive Director will provide oversight to ensure compliance.