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. 13, 2022 and Jan. 14, 2022

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 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:

1. During medication cart audits, always check the manufacturers' expiration dates along with all rewritten dates to ensure accuracy. Also, ensure all medications either have a pharmacy label or the first and last name of the resident written on the bottle. 2. First aid for maintenance staff 3 expired 12/18/2021. Ensure he completes the class that he is currently enrolled in for 2/14/2022. 3. Ensure all old forms are destroyed as one new resident had an old physical form completed. Ensure physicians' have the current form as well. 4. The tuberculin skin test/assessments for residents 3 and 4 expire this month. 5. Carefully review the uniform assessment instruments completed by case workers and if information is inaccurate or incomplete, ensure documentation is kept of the immediate notification of case worker as well as all follow-up contacts.

Comments:

An unannounced renewal inspection was conducted on 1/13/2022 from approximately 8:20 am to 5:00 pm and on 1/14/2022 from approximately 7:30 am to 11:00 am. Upon arrival there were 16 residents in care and two staff on duty. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. The posted menu included substitutions and thus accurately reflected this inspector's observations. The lunch meal was observed and the one special diet was served according to the physician's order. Medication administration observations were completed with four residents and one registered medication aide. The January 2022 medication administration records, physicians' orders and medications were reviewed for all four residents observed. Individual interviews were conducted with residents; however, there were no family members available to interview. The areas of non-compliance included resident orientation, uniform assessment instruments, dietary oversight, medications, individualized service plans, menus and pet examinations/immunizations. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-410-A
Description:	Based upon documentation and an interview, the facility failed to ensure three of the four residents' orientations were provided upon admission. Evidence: 1) Resident 1 (admitted 11/30/2021) signed that orientation and written agreement were completed on 11/9/2021; resident 2 (admitted 8/26/2021) signed that orientation and agreement were completed on 7/15/2021; resident 3 (admitted 1/22/2021) signed that orientation and agreement were completed on 1/12/2021. 2. On 1/13/2022, the licensing inspector (LI) interviewed the administrator and staff 2 and both stated the residents received the orientation when the agreements were signed and that the dates of orientation completion were correct. Both stated no additional orientations were completed upon the residents' admission.
Plan of Correction:	A new form will be created, completed and signed by the resident on the day of admission to verify the staff reviewed the meal times, use of the call bell system and emergency response procedures on the day of admission. This form will be used when the admission date is different from the date the agreement is signed. The administrator will review all paperwork prior to and on the day of each resident's admission to ensure all required paperwork is accurate and complete.
Standard #:	22VAC40-73-440-A
Description:	Based upon documentation and an interview, the facility failed to ensure two of five residents' uniform assessment instruments (UAIs) were completed annually. Evidence: 1. The initial UAI for resident 3 (admitted 1/22/2021) was completed on 12/1/2020 and was the only UAI on file. 2. The initial UAI for resident 4 (admitted 2/1/2021) was completed on 1/7/2021 and was the only UAI on file. 3. On 1/13/2022, the LI interviewed staff 2 who stated these were the only UAIs on file for these residents and she confirmed the caseworkers had not been contacted by the facility to update the UAIs.
Plan of Correction:	Each resident's record was reviewed by the administrator and staff 2 and a chart was created that includes the review dates of the UAIs, individualized service plans (ISPs), tuberculin skin tests/assessments, and physicals. The caseworkers were informed of all of the upcoming due dates for the UAIs. The UAIs for residents 3 and 4 were received on 1/14/2022 and the ISPs were also completed on that date. The newly created chart will be reviewed and updated monthly and caseworkers will be notified at least one month prior to the UAI annual review date and whenever the resident's condition changes. The notification will be documented in the resident's record by staff 2 or the administrator. Staff 2 will ensure all UAIs are updated/completed as required and within the required timeframes. The administrator will review the UAIs each month to ensure compliance.
Standard #:	22VAC40-73-450-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of five residents' ISPs was completed on or within seven days of admission. Evidence: 1. Resident 2 (admitted 8/26/2021) had an ISP signed and dated as completed on 7/15/2021). 2. On 1/13/2022, the LI interviewed staff 2 who stated the ISP was completed as required and then the resident decided not to move in right away. Staff 2 also stated staff did not review and resign the ISP within seven days of the actual admission date or on the day of admission.
Plan of Correction:	Staff 2 had resident 2 sign his ISP and his UAI was redone. Staff 2 will complete each new resident's ISP within seven days prior to the day of admission or on the day of admission. The administrator will review the ISP prior to the resident signing it to ensure all information is accurate and complete. Staff 2 or administrator will review the ISP with the resident on the day of admission, have the resident sign the ISP on the day of admission and give the resident a copy of the ISP on the day of admission. Staff 2 and the administrator will review the ISPs monthly to ensure they are completed, updated and accurate.
Standard #:	22VAC40-73-610-B
Description:	Based upon observations, documentation and an interview, the facility failed to ensure snacks for the current week were included on the posted menu. Evidence: 1. On 1/13/2021 at approximately 8:30 am, the LI observed the current posted menu on the bulletin board at the entrance of the facility. The menu did not include snacks but had a statement at the top that, "Snacks are available at all times." 2. On 1/13/2022, the LI interviewed the administrator who stated she changed the menu format and thought since snacks had to be available at all times she only needed to state that information on the menu and no longer needed to list the specific snacks to be available each week.
Plan of Correction:	Administrator put a space on menu for snacks, listed what snacks are available for the week and added a space for substitutions at the bottom of the menu. The menu was corrected while the LI was in the facility. The administrator will ensure the snacks are included on the weekly menu and staff 2 will review the menu each week prior to it being posted to ensure compliance.
Standard #:	22VAC40-73-620-A
Description:	Based upon documentation, the facility failed to ensure the dietary oversight was completed at least once every six months for one of five residents' records reviewed. Evidence: 1. The last dietary oversight was signed as completed on 2/24/2021. 2. On 1/13/2022, the LI interviewed the administrator and staff 2 and both stated 2/24/2021 was the last time the dietician conducted an oversight. Both also stated they had not contacted the dietician to conduct an oversight for August 2021.
Plan of Correction:	Dietician was called several times while LI was in the facility and messages were left; however, no one has called back. Facility is trying to find another dietician to start coming in for oversights. As soon as the facility finds one, the LI will be informed. The administrator will contract with another dietician and will contact her/him at least once every six months to ensure the dietary oversights are conducted at least once every six months, starting in February. The administrator will review the dietician's oversight to ensure it includes all of the required information listed in the standard and will ensure the information is submitted within the required timeframe.
Standard #:	22VAC40-73-680-G
Description:	Based upon observations and an interview, the facility failed to ensure two of the approximately 25 over the counter (OTC) medications reviewed were labeled with a pharmacy label or the residents' names. Evidence: 1. On 1/13/2022, the LI conducted an audit of the medication cart and observed a bottle of Melatonin and Sleep-Aid that did not have pharmacy labels or the residents' names written on the bottles. 2. On 1/13/2021, the LI interviewed staff 2, the registered medication aide on duty, and she stated the bottles were not labeled with pharmacy labels or the residents' names.
Plan of Correction:	Staff 2 overlooked writing residents' names on the bottles of Melatonin and Sleep-Aid. Staff 2 put the names on the bottles and double checked the medication cart to see if any other medications were left unmarked. Administrator and staff 2 will immediately write the resident's name on any medications that are received that do not have a pharmacy label. Staff 2 and administrator will check the medication cart monthly and sign a checklist sheet to make sure all medications are labeled with the residents' first and last names.
Standard #:	22VAC40-73-840-B
Description:	Based upon documentation and interviews, the facility failed to ensure two of the eight pets that live on the premises had all the required immunizations and annual physicals. Evidence: 1. The last pet immunization and physical examination information on file for resident 2's pet was dated as completed 6/22/2020. The rabies vaccination expired 6/22/2021. 2. The last pet physical examination information on file for resident 9's pet was dated as completed 5/20/2020. 3. On 1/14/2022, the LI interviewed staff 2 and the resident and both stated the pet's annual examination had not been completed. Staff 2 also stated the immunizations were not current for resident 9's pet.
Plan of Correction:	While LI was at the facility, the veterinarian was called and appointments were scheduled for the pets. Resident 2's pet was taken on 1/20/2022 and received an examination and rabies shot. Resident 9's pet has an appointment for 1/27/2022. Copies of the completed examinations and vaccinations will be sent to the LI. A chart was created that lists all of the pets and their due dates for examinations and vaccinations. The chart will be reviewed and updated by staff 2 and the administrator at least monthly to ensure all examinations and vaccinations are scheduled and completed within the required timeframes. Copies of all pet vaccinations and annual examinations will be kept in a facility file to ensure compliance.