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: March 9, 2021 , March 10, 2021 and March 11, 2021

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 63.2 General Provisions. 63.2 Protection of adults and reporting. 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

Technical Assistance:

1) Carefully review physicians' orders immediately upon receipt and ensure all information is included. When a diagnosis or any other information is missing, fax the order back to the physician and request the diagnosis/missing information be added. 2) Forward the health inspection or email from the health inspector regarding annual inspection. 3) When a resident self-administers only one or a portion of medications, ensure the name of the self-administered medication, as well as the date of the order stating resident may self-administer that specific medication, are noted on the uniform assessment instrument under medication management. 4) The sheet that lists the type of staff in the facility should not include staff names - only positions (please refer to 410.B). 5) A new drug reference book needs to be obtained before the end of this year. 6) Recommended adding a column to the fire drill form and log sheet for corrective actions taken for problems encountered.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 3/9/21 and concluded on 3/11/21. The staff in charge was contacted by telephone to initiate the inspection. The staff in charge reported that the current census was 13. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two staff and two resident records, activities calendar, menu, staff schedules, fire drills, medication administration records, physicians' orders, as-needed medications in the medication cart, medication pharmacy reviews, dietitian's reviews, health care oversights, as well as other documents. Selected sections of additional records were also reviewed for one staff, two contract staff and nine resident records to ensure previous violations were corrected. A virtual inspection and tour were conducted along with the desk review. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based upon documentation and an interview, the facility failed to ensure one of three staff had verification of receipt of a job description. Evidence: 1) Staff A had no signed job description or verification of receipt of a job description on file. 2) On 3/11/21, the licensing inspector (LI) interviewed staff C who stated this information was not on file.
Plan of Correction:	We have not hired anyone in years so we overlooked the proper paperwork for a job description. We have put a new job description in place that staff A has already signed. Staff C will make sure any new hire signs a job description immediately upon hire. Staff C will also make sure this document is put into the new hire's chart. The administrator will review each new hire's chart upon the day of hire and one week later to ensure all information has been completed as required.
Standard #:	22VAC40-73-650-B
Description:	Based upon documentation and an interview, one of the three residents' physicians' orders reviewed did not include a diagnosis. Evidence: 1) The signed orders for resident B did not include a diagnosis for Amitriptyline, Losartan, Prazosin, Risperidone, Dulera and Benzonatate. 2) On 3/11/21, the LI interviewed staff C who stated she did not have a diagnosis from the physician for these medications.
Plan of Correction:	Sometimes with new admissions, they do not always have a diagnosis for each medication. A new form was created to be sent to the doctor's office requesting the diagnosis for any medication order that does not include a diagnosis or any other required information. Staff C will send the request form to the doctor's office immediately upon receipt of the incomplete order and will follow-up to ensure the information is obtained. Staff C will allow five days for the doctor to return the form and if it is not returned, staff C will contact the doctor's office to request the missing information. If the information is still not received, then staff C will contact the facility's pharmacy for assistance to ensure all information is obtained within 14 days of admission/receipt of order. The administrator will review all orders within seven days of receipt to ensure compliance.