VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Eden Senior Care Services
15120 Enterprise Court, Suite 101
Chantilly, VA 20151
(703) 828-7545

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: July 17, 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 63.2- (1) GENERAL PROVISIONS 63.2- (16) PROTECTION OF ADULTS AND REPORTING 63.2- (17) LICENSURE AND REGISTRATION PROCEDURES 63.2- (19.2) CRIMINAL PROCEDURES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring July 17, 2024, from 12:35 pm -4:00pm the licensing inspector was on-site at the facility for each day of the inspection. 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with participants: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Bingo, lunch, and exercise. 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 Jacquelyn Kabiri, Licensing Inspector at 703-397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-50-E
Description:	Based on participant record review the center failed to review the rights and responsibilities of participants annually with each participant. Evidence: 1. Participant 1?s rights form was signed on March 16, 2022, with no annual review date. 2. Participant 2?s rights form was signed on June 15, 2022, with no annual review date.
Plan of Correction:	Staff will review participant files for completeness and ensure the two participants' files are updated
Standard #:	22VAC40-61-170-F
Description:	Based upon documentation, and staff interview, the center failed to ensure volunteers attended an orientation that included a description of duties, responsibilities, participant rights, confidentiality, emergency procedures, infection control, and reporting requirements. Evidence: 1.During an interview with the LI staff 1stated that the center has 2 volunteers. 2. Staff 1 stated that the 2 volunteers did not have a signed and dated statement that they attended an orientation with information on: a. Confidentiality b. Participants rights c. Emergency procedures d. Infection control e. Their duties and responsibilities f. Their supervisor?s name. g. Reporting requirements
Plan of Correction:	Volunteers will receive orientation training and statements signed
Standard #:	22VAC40-61-190-C
Description:	Based on facility records and interviews, the facility failed to maintain a daily participant attendance log, documenting the name of the participant and his arrival and departure time. Evidence: 1. Official attendance records indicate 57 participants daily. 2. Staff 1 provided the LI with an "unofficial list? of 16 participants. 3. Monthly fire and emergency evacuation drills indicate a discrepancy in the number of daily participants. A. Jan 03, 2024, 10:30 am, 23 staff and 86 participants evacuated during the drill. The number of unofficial participants in the 86 count is unclear. Twenty-three staff evacuated, but the staff list has only 15 employed by the center. B. Feb 05, 2024, 9:50 am, 22 staff and 94 participants evacuated during the drill. The number of the unofficial participants in the 94 count is unclear. Twenty-two staff evacuated, but the staff list has only 15 employed by the center. C. March 04, 2024,10:20 am, 21 staff and 91 participants evacuated during the drill. The number of the unofficial participants in the 91 count is unclear. Twenty-one staff evacuated, but the staff list has only 15 employed by the center. D. April 02, 2024, 10:15 am, 21 staff and 95 participants evacuated during the drill. The number of the unofficial participants in the 95 count is unclear. Twenty-one staff evacuated, but the staff list has only 15 employed by the center. E. May 07, 2024, 9:40 am, 20 staff and 94 participants evacuated during the drill. The number of the unofficial participants in the 94 count is unclear. Twenty staff evacuated, but the staff list has only 15 employed by the center. F. June 03, 2024, 9:40 am, 22 staff and 96 participants evacuated during the drill. The number of the unofficial participants in the 96 count is unclear. Twenty-two staff evacuated, but the staff list has only 15 employed by the center. G. July 03, 2024, 9:55 am, 22 staff and 96 participants evacuated during the drill. The number of the unofficial participants in the 96 count is unclear. Twenty-two staff evacuated, but the staff list has only 15 employed by the center.
Plan of Correction:	Employee staff lists have been updated to correct number of staff employed by the center. Sign in rosters will be implemented for participants who do not regularly attend center. Staff will be reminded of the necessity to ensure daily attendance is accounted for accurately.
Standard #:	22VAC40-61-250-A
Description:	Based on record review and interview, the center failed to ensure established policies and procedures for documentation and recordkeeping to ensure that the information in participant records is accurate, clear, and well organized. 1. Staff 1 provided the names of 16 unofficial participants who are regularly attending the center. 2. The center record keeping is not clear or accurate, between participants attending and participants attending ?unofficially?.
Plan of Correction:	Staff will continue to improve organization of record keeping for participants who regularly attend and those who attend infrequently.
Standard #:	22VAC40-61-250-B
Description:	Based on record review and interview, the center failed to ensure personal information shall be kept current for each participant: Full name of participant, address, and telephone number, date of admission and birth date. Evidence: 1. The unofficial participants do not have records to verify they meet the minimum admission requirements. 2. LI asked for the files of the 16 unofficial participants and Staff 1 stated they did not have any.
Plan of Correction:	Staff will review and update files for regular participants and infrequent participants Staff will develop files for infrequent attendees
Standard #:	22VAC40-61-260-A
Description:	Based on observation and interview, the center failed to ensure participants have physical examinations within 30-days preceding admission, a participant shall have a physical examination by a licensed physician. Evidence: 1. Staff 1 provided a written list of unofficial participants that do not have a physical exam before attending the center. 2. LI asked for the files of the 16 unofficial participants and Staff 1 stated they did not have any.
Plan of Correction:	Staff will develop files for infrequent attendees Staff will monitor progress of getting infrequent attendee preadmission exams
Standard #:	22VAC40-61-260-B
Description:	Based on observation and staff interview, the center failed to ensure that participants obtained an evaluation by a qualified licensed practitioner that completes an assessment for TB (Tuberculosis) in a communicable form no earlier than 30 days before admission. Evidence: 1.16 unofficial participants attend the center without a TB screening or evaluation and record. 2. Staff 1 verified there are 16 unofficial participants.
Plan of Correction:	Staff will work with infrequent attendees to ensure TB tests are done and ensure future attendees have test before admission
Standard #:	22VAC40-61-300-A
Description:	Based on direct observation and record review, the center failed to have, keep current, and implement a plan for medication management. The center?s medication management plan shall address procedures for administering medication. Evidence: 1. The center stores participant medication in the clinic room in the wall cabinet and mini refrigerator. 2. On July 17, 2024, the Licensing Inspector (LI)requested the medication management plan during the inspection, but Staff 1 was unable to provide it. 3.On July 15, 2024, the LI requested the medication management plan it was not provided. 4.Photos taken as evidence.
Plan of Correction:	Eden does not administer medications. Medications noted in findings have been removed from center.
Standard #:	22VAC40-61-300-E-2
Description:	Based on direct observation, the center failed to ensure that all medication shall be labeled with the participant?s name, the name of the medication, the strength and dosage amount, the route of administration and the frequency of administration. Evidence: 1. The clinic room has 2 top cabinets containing medications or medication items that are unlabeled. 2. Two Restasis tubes of liquid medication found with no name or labeled prescription container, in upper cabinet 2. 3. In upper cabinet 1, one bottle of Tums, one bottle of acetaminophen, one bottle of Tylenol, one bottle of Advil, and one bottle of Icosaoent, were all unlabeled with no participant?s names or identifying information. 4. Located in upper cabinet 2, one box of prescription lidocaine patches 5%, were located without a prescription label. 5. Two Insulin Lispro injection pens were located in the clinic mini refrigerator, inside an unlabeled, open container. 6. Photos taken as evidence.
Plan of Correction:	Medications noted in findings have been removed from center except over the counter medications.
Standard #:	22VAC40-61-410-E
Description:	Based on direct observations during the building tour, the center failed to ensure that cleaning products or harmful materials, were stored and kept in a locked place when not in use. Evidence: 1. The laundry/storage room adjacent to the water fountain was unlocked and the door did not have a locking mechanism on the doorknob. 2. The unlocked laundry/storage room had one large bottle of Clorox bleach, and liquid laundry soap out in the open. 3. Photos taken as evidence.
Plan of Correction:	Lock added to laundry room door