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:

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 & 02/08/2024 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 1/10/2024 regarding allegations in the area of personnel. 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: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 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 #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based upon a record review and staff interview conducted during a complaint inspection that took place of 02/01/2024 and 02/08/2024, the facility failed to have a documentation to show the coordinated plan of care on the Individualized Service Plan (ISP) between the facility and the Hospice agency for one of two records. Evidence: Resident A's ISP, dated 10/20/2023, had no documentation of a coordinated plan of care and services required between the facility and the Hospice agency.
Plan of Correction:	Resident Wellness Director with the assistance of the Resident Care Director or designee will review all current Hospice Resident ISP?s for accuracy and will ensure that all ISP?s include the services form the plan of care that will be provided by the Hospice company for those residents and update upon changes and yearly. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on resident record review and staff interview, it was determined that the facility staff failed to adhere to the medication management plan. Evidence: 1. Two nursing staff failed to document the narcotic counts for residents in care of the change of shift as required. 2. The December 2023 Controlled Drug Count Sheet was missing two person signatures for 15 out of 31 days on day shift; 8 out of 31 days on the evening shift; and 18 out of31 days for night shift. 3. The January 2024 Controlled Drug Count Sheet was missing two person signatures for 5 out of 31 days for day shift; 5 out of 31 days for evening shift, and 14 out of 31 days for night shift. 4. The December 2023 and January 2024 Controlled Drug Count Sheet were missing two person signatures for all three shifts for 12 out of 31 days for January 2024.
Plan of Correction:	Resident Wellness Director will review The Warren medication administration plan with all med techs to ensure proper documentation of all Controlled Drug Counts sheets requiring two medication aide/nurse signatures at each shift/staff change. Resident Wellness Director will monitor for accuracy and consistency of Narcotic Count Sheets to maintain compliance. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on direct observation of Licensing Inspector 2, the facility failed to administer physician ordered medications within the timeframe as required. Evidence: 1. Resident A received 12 pills from the medication aide at 10:03am on 2/1/2024 though the medication was ordered for 8am. 2. Resident B received 12 pills from the medication aide at 9:55am on 2/1/2024 though the medication was ordered for 8am.
Plan of Correction:	Wellness Director will review late medications with all medications aides and ensure that proper documentation and notification to physicians that is consistent with the Standards of Practice outlined in the curriculum approved by the Virginia Board of Nursing for Medication Aides. Executive Director will provide oversight to ensure compliance
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based upon a review of records, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions. Evidence: 1. Resident A is scheduled to receive one tablet of Hydrocodone/APAP at approximately 6am, 10am, 2pm and 6pm daily. 2. According to the Controlled Drug Administration Sheet on 1/8/2024, Resident A received Hydrocodone/APAP, one tablet at approximately the following times: 5:06am, 9:00am, 10:43am, 1:37pm and 6pm. 3. According to the Controlled Drug Administration Sheet on 1/9/2024, Resident A received Hydrocodone/APAP one tablet at approximately the following times: 6am, 10:26am, 1:12pm, 5:27pm and 7:37pm.
Plan of Correction:	Resident Wellness Director or designee will ensure that medications are administered in accordance with the physician?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. ? New medication orders and/or refills will be provided within 24 hours. ? Medication will be available at time of administration. ? Resident Wellness Director or designee will monitor medication pass quarterly on medication aides. ? Licensed nursing staff will review the electronic medication administration records (EMAR?s) routinely for accuracy, correctness and proper documentation to include holes or omissions in EMAR?s. Executive Director will provide oversight to ensure compliance.