VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Maple Lawn Residential Living
2526 Lee Jackson Highway
Staunton, VA 24401
(540) 337-2109

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Jan. 6, 2020 and Jan. 8, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Areas in which questions were answered or clarification was provided: 1) Changes to the staff schedule need to be included on the schedule and not just listed on a separate sheet of paper and attached. 2) Tuberculin skin test/assessment for staff B is due by the end of this week. 3) The posted list with various emergency phone numbers for the facility that is posted in the dining and living rooms needs to be updated. (Note: The required numbers were posted). 4) Discussed the breakfast menu and the need for more variety during the week. 5) Need to add fish to the pet policy as are now allowing them. 6) Even if give emergency personnel a medication list, they must also be given a copy of the current medication administration record.

Comments:

An unannounced renewal inspection was conducted on 1/6/20 from approximately 6:20 am to 6:40 pm and 1/8/20 from approximately 8:00 am to 3:00 pm. Upon arrival there was one staff on duty and 15 residents in care. All of the required postings were in place and the facility was clean and free from any foul odor. The activities calendar and menu accurately reflected this inspector's observations. The special diet observed was served according to the physician' order and the resident also indicated the appropriate diet was served. Medication administration observations were completed for four residents and one registered medication aide. The medication administration records, physicians' orders and medications were reviewed for all four residents. Individual interviews were conducted with residents, outside agency staff and facility staff. The areas of non-compliance included the disclosure form, reporting major incidents, reviews of sex offender registry information, individualized service plans, dietary oversight, implementation of the medication management plan and availability of as-needed medication. Two of the previous eight violations were repeat violations. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection. NOTE: The last fire inspection was completed on 1/9/19 and must be completed prior to a new license being issued. Upon completion, please immediately forward the fire inspection report to the licensing office.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based upon documentation and an interview, the facility failed to ensure the most current disclosure form was used for three of three new residents admitted since the last inspection. Evidence: 1) The disclosure form signed as received by residents A (admitted 12/13/19), B (admitted 6/1/19) and C (admitted 4/13/19) did not include initials on the bottom of each page and for resident A, it also did not include information regarding a generator. 2) On 1/6/20, the licensing inspector (LI) interviewed staff B who stated the new form was not being used.
Plan of Correction:	The new model disclosure form will be completed with all of the required information and then sent to the inspector for review. Upon approval, the new disclosure form will be implemented and reviewed and signed by all residents. The administrator will ensure all future changes are implemented immediately.
Standard #:	22VAC40-73-70-A
Description:	Based upon documentation and an interview, the facility failed to ensure two of five incidents were reported to the licensing office. Evidence: 1) Resident B had a fall on 7/1/19 and resident C had a fall on 7/13/19. Both falls resulted in the residents being sent to the emergency room. 2) On 1/6/20, the LI interviewed staff B who stated she was not aware she had to report the incident if 911 was not called and instead family or staff took residents to the emergency room.
Plan of Correction:	Incident reports will be submitted to the LI on residents B and C. All incidents that affect the life, health and safety of any resident will immediately (within 24 hours) be reported to the licensing inspector and a full report will be submitted within seven days. The administrator will review each incident report prior to submission to ensure compliance
Standard #:	22VAC40-73-350-C
Description:	Based upon record reviews and an interview, the facility failed to ensure three of the three new residents were informed prior to or at admission of information regarding registered sex offenders and how to obtain such information. Also, three of the three current residents' records reviewed had no verification of an annual review of this information. Evidence: 1) Residents A, B and C did not have verification on file of having received the sex offender registry information. Also, there was no documentation on file for residents D, E and F of an annual review of this information. 2) On 1/8/20, the LI interviewed staff B who stated this information had not been reviewed with the residents.
Plan of Correction:	A new form will be created for all current residents to sign to acknowledge review of the sex offender registry information. The form will also be signed by all new residents upon admission and annually and will be maintained on file. The administrator will review all admission paperwork upon the day of admission and will audit the annual review to ensure compliance.
Standard #:	22VAC40-73-450-F
Description:	Based upon record reviews and an interview, the facility failed to ensure four of the six individualized service plans (ISPs) were updated as the residents' needs changed. Evidence: 1)The ISP (completed 6/1/19) for resident B did not include a pureed diet and fall risk. 2)The ISP (completed 10/18/19) for resident C did not include ability to self-administer Tretinoin, a hospital bed with one half rail, allergic reactions and fall risk. The ISP indicated resident received mental health services monthly; however, they were received every four months. 3) The ISP (completed 9/13/19) for resident D indicated resident self-administered Triamcinolone Cream; however,the cream was discontinued on 11/12/19. 4) The ISP (completed 9/13/19) did not include the allergic reaction to penicillin. 5) On 1/6/20, the LI interviewed staff B who stated these needs were not included on the residents' ISPs.
Plan of Correction:	All corrections were made on the ISPs and the ISPs were updated after receiving new orders from the doctors. Staff B will go over doctors' paperwork when residents come from their appointments and will make any necessary changes to the ISPs . The administrator will review the changes made and initial the ISPs after the reviews are completed.
Standard #:	22VAC40-73-620-B
Description:	Based upon documentation, the facility failed to ensure the dietitian's recommendations, upon receipt, were reported to the residents' physicians and that the actions taken in response to the recommendations were documented in the residents' records for six of the nine residents reviewed. Evidence: 1) The dietary oversight completed 8/7/19, had recommendations for residents B, G, H, I, J and K; however, there was no documentation on file that facility staff contacted the residents' physicians nor was there any documentation of any actions staff took in response to the recommendations. 2) On 1/8/20, the LI interviewed staff B who stated this information had not been documented. .
Plan of Correction:	Staff A or B will document recommendations from the dietitian on the residents' meal sheets and will chart any changes made to their diets. Staff A or B will have the dietitian's recommendations and the doctor's approval or disapproval of the recommendations signed by the doctor and will file this information in the residents' charts. The administration will ensure the actions taken by the facility staff to implement the approved recommendations are documented in the dietitian's notebook.
Standard #:	22VAC40-73-640-A
Description:	Based upon documentation, the facility failed to keep current and implement a medication management plan that ensured medication orders were transcribed to the medication administration records (MARs) within 24 hours of receipt of a new order and that methods for monitoring medication administration, the effective use of the MARs for documentation were implemented and that medications were disposed of properly for two of the four residents records reviewed. Evidence: 1) Resident C had a signed order dated 12/20/19 for Pantoprazole one 20mg tablet every day on an empty stomach. The medication was in the medication cart packaged together in one bubble pack with three other medications; however, the Pantoprazole was not listed on the January MAR. The LI interviewed staff B who showed this LI the December MAR where the medication was listed. Staff B stated she failed to document this medication on the January MAR as the pharmacy had not listed it and she did not add it on. 2) Resident C also had a signed physician's order dated 12/24/19 for Ondansestron one 4mg table for nausea three times a day as-needed. This medication was also not listed on the January MAR. 3) On 1/6/20, the LI conducted a medication cart audit and observed a package of Hydroxyzine for resident G. The order for Hydroxyzine was discontinued in March 2019. The medication was not listed on the MAR and according to staff B the medication had not been administered since it was discontinued. On 1/6/20, the LI interviewed staff B and she stated she failed to dispose of the medication. 4) Resident G had a signed order dated 7/18/19 for Cyclobinzaprine one 5mg tablet every eight hours as needed for muscle spasms; however, this medication was not documented on the January MAR. On 1/6/20, the LI interviewed staff B and she stated she had not transferred this information onto the January MAR.
Plan of Correction:	Pantoprazole and Ondansestron were added to resident C's MARs. The new signed order to discontinue Hydroxyzine was obtained and filed in resident G's record. Hydroxyzine was noted as discontinued on resident G's MAR. All new orders a doctor writes will be added by staff B onto the residents' MARs and physician's order form within 24 hours and upon arrival from the doctor's visit. The new order will be kept in front of the medication chart in the medication notebook to be reviewed by the administrator at least weekly to ensure any new changes are documented accurately and then can be added to the next months MAR.
Standard #:	22VAC40-73-680-M
Description:	Based upon observations, documentation and an interview, the facility failed to ensure one as-needed (PRN) medication was available for one of four resident records reviewed. Evidence: 1) Resident A had a signed PRN order (dated 10/22/19) for Acetaminophen. 2) On 1/6/20, the licensing inspector (LI) checked the medication cart and observed there was no Acetaminophen for resident A. 3) Staff B also checked the medication cart and stated there was no Acetaminophen available for resident A; however, according to an interview, resident A had not requested the medication since she was admitted to the facility.
Plan of Correction:	A new order was obtained for resident A and Acetaminophen was delivered to the facility. Staff A and B will check all new orders and all current scheduled and PRN orders to ensure all medications are available at the facility. Staff A and B will check all new and changed orders and will immediately document them on the MARs. The administrator will review the changes and documentation upon receipt to ensure accurate documentation. Staff A and B will conduct a medication cart audit at least once a month. The cart audit will include checking the current physicians' orders to the MARs and checking the order and MARs to the actual medications to ensure the MARS are accurate and that all medications are available and on site. The administrator will ensure compliance with this standard.