VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Washington Senior Healthcare Center
5300 Shawnee Road
Suite #101
Alexandria, VA 22312
(703) 354-4590

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Oct. 7, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS

Technical Assistance:

None

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/07/2024 Time In: 10:47 AM Time Out: 2:08 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 140 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI toured the physical plant of the facility. LI observed participants entering and exiting the center for community activities, interacting with staff and peers, utilizing the exercise equipment and activity rooms, playing bingo, preparing coffee, tea, and water, and eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 applicable standard(s) 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 the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-140-B
Description:	Based on staff record review, the facility failed to ensure that direct care staff met one of the requirements at the time of employment or within 60 days of hire. Evidence: Staff 3 (hire date, 09/19/2022) personal care aide certification was completed on 01/06/2023.
Plan of Correction:	The director will ensure that all participants undergo a physical examination conducted by a licensed physician within the 30-day period preceding their admission. The results will be reviewed and documented to confirm that each participant meets the health requirements necessary for admission and participation.
Standard #:	22VAC40-61-160-B
Description:	Based on facility record reviews, the facility failed to ensure that three out of the four direct care staff reviewed had current certification in CPR from American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult CPR or include adult CPR. Evidence: 1. Staff 2 (hire date, 05/18/2024) record included a first aid certification (07/09/2024) issued by National CPR Foundation. 2. Staff 3?s (hire date, 09/19/2024) record included a first aid certification (07/09/2024) issued by National CPR Foundation. 3. Staff 4?s (hire date, 07/04/2016) record included a first aid certification (07/09/2024) issued by National CPR Foundation.
Plan of Correction:	The Director will ensure that all direct care staff receive CPR training from designated CPR training institution.
Standard #:	22VAC40-61-240-A
Description:	Based on resident record review, the facility failed to ensure that at or prior to the time of admission, there shall be a written agreement between the participant and the center. The agreement shall be signed and dated by the participant or legal representative and the center representative. Evidence: Participant 8?s (admit date, 05/28/2024) participant agreement with the center was not signed and dated by the center representative.
Plan of Correction:	The director will ensure that all necessary agreements, including consent forms and required documentation are promptly signed and dated by both participants and center representative at the time of admission. This process will be carefully monitored to verify that each agreement is completed in full, with accurate dates and signatures.
Standard #:	22VAC40-61-260-A
Description:	Based on resident record review, the facility failed to ensure that within 30 days preceding admission, a participant shall have a physical examination by a licensed physician. Evidence: Participant 2?s (admit date, 03/18/2024) physical examination was dated 04/08/2024, three weeks after admission.
Plan of Correction:	The director will ensure that all participants have physical examination by a licensed physician within 30 days preceding admission.
Standard #:	22VAC40-61-260-B
Description:	Based on resident record review, the facility failed to ensure that the report of the required physical examination included height, weight, and blood pressure for one of the eight resident records reviewed. Evidence: Participant 2?s (admit date, 03/18/2024) physical examination (04/08/2024) was missing height, weight, and blood pressure.
Plan of Correction:	The center will ensure that all sections of the physical examination are completed by the doctor?s office. If any section is found incomplete, the center staff will contact the doctor?s office to request completion. Should the doctor?s office not cooperate with this request, the director will document this on the form for record-keeping.
Standard #:	22VAC40-61-260-C
Description:	Based on resident record review, the facility failed to ensure that each participant submitted a physical examination by a physician and any recommendations for care including: any special diet or any food intolerances for one of the eight residents reviewed. Evidence: Participant 5?s (admit date, 02/03/2020) physical examination (05/10/2024) was missing any special diet or any food intolerances.
Plan of Correction:	The center will ensure that all sections of the physical examination are completed by the doctor?s office. If any section is found incomplete, the center staff will contact the doctor?s office to request completion. Should the doctor?s office not cooperate with this request, the director will document this on the form for record-keeping.
Standard #:	22VAC40-61-410-A
Description:	Based on Licensing Inspector (LI) observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair, kept clean and free of rubbish, and free from safety hazards. Evidence: 1. On 10/07/2024, LI toured the center and observed wet towels on the floor in various areas: the water station in the lobby, in between two sinks in the women?s bathroom, and next to a trashcan in the common room. 2. On 10/07/2024, LI toured the center and observed an overflowing trash can in the women?s bathroom. The trashcan was full with used paper towels, toilet tissue, and a water bottle on the floor surrounding the can. 3. On 10/07/2024, LI toured the center and observed rollators blocking access to a stairwell. 4. On 10/07/2024, LI toured the center and observed rollators propping open a door and blocking a fire exit. 5. Photo evidence taken.
Plan of Correction:	The director will conduct a thorough review of all areas identified during this inspection that require attention or improvement. The director will work to establish protocols to enhance ongoing compliance, and ensure measures are part of a continuous effort to maintain the center in top condition, providing a safe and clean environment that meets the highest standards for participants.
Standard #:	22VAC40-61-550-A
Description:	Based on Licensing Inspector (LI) observation, the facility failed to ensure that each building of the center and all vehicles being used to transport participants contained a first aid kit that included: antiseptic cleansing solution, bee sting swabs or preparation, thermometer, and disposable single-use breathing barriers or shield for use with breathing or Cardiopulmonary Resuscitation (CPR) (e.g., CPR mask or other type). Evidence: The first aid kit did not include antiseptic cleansing solution, bee sting swabs or preparation, thermometer, and disposable single-use breathing barriers or shield for use with breathing or CPR (e.g., CPR mask or other type).
Plan of Correction:	The Director will take prompt action to replenish all missing items in the first aid kit and will continue to monitor the kit regularly to ensure ongoing compliance. The Director will verify that the identified items are restocked promptly and will implement a routine inspection schedule to confirm that all required first aid supplies are consistently available and in good condition.
Standard #:	22VAC40-80-120-E-2
Description:	Based on LI observation, the facility failed to ensure that the findings of the most recent inspection of the facility were not posted. Evidence: On 10/07/2024, LI observed an Inspection Summary dated 10/04/2021 posted on the bulletin board. The most recent inspection
Plan of Correction:	The director will ensure that the findings from the most recent facility inspection are clearly posted on the designated bulletin board, located in a visible and accessible area within the center. This posting will occur promptly after each inspection has been completed and once the inspection summary has been finalized.