VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heatherwood Independent and Assisted Living
9642 Burke Lake Road
Burke, VA 22015
(703) 425-1698

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: June 6, 2024

Complaint Related: No

Areas Reviewed:

Areas of Standards Reviewed: MARK AREAS REVIEWED AREAS OF STANDARDS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2- (1) GENERAL PROVISIONS 63.2- (16) PROTECTION OF ADULTS AND REPORTING 63.2- (17) LICENSURE AND REGISTRATION PROCEDURES 63.2- (18) 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

Comments:

Date of the inspection: 06/06/2024, 8:30 AM to 4:00 PM. Type of inspection: Monitoring The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 111. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8. Number of staff records reviewed: 6. Number of interviews conducted with residents: 2. Number of interviews conducted with staff: 1. Observations by licensing inspector: Meals, Activities, Medication Pass An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined noncompliance with applicable standard(s) or law, and violations 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 #:	22VAC40-73-100-A
Description:	Based on record review and staff interviews, the facility failed to ensure an annual review of infection prevention policies and procedures for any necessary updates. A licensed health professional, with training in infection prevention, shall be included in the review to ensure compliance with guidelines and regulations, and documented at the facility. Evidence: 1. The facility's infection control policies and procedures manual are dated October 04, 2019. 2. The facility does not have written documentation of an annual review of current infection control policies. 3. During an interview with staff 9, she stated that the October 4, 2019, policies, and procedures manual is the most current. The facility has no record or annual review with staff.
Plan of Correction:	In respect to the specific resident/situation cited: Infection control policy manual was reviewed by Executive Director of Infection Preventionist, Director of Clinical Services and Environmental Services Director on June 7 ,2024. With respect to what systemic measures have been put into place to address the stated concern: Annual training and review of Infection Prevention Policies and Procedures will be conducted every June.
Standard #:	22VAC40-73-450-E
Description:	Based on the resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed by the resident and/or the resident?s legal representative. Evidence: 1. Resident 6 has an (ISP) dated 11/20/2023 that is not signed by resident or the legal representative. 2. Staff 9 confirmed the ISP was unsigned by the resident or the resident?s legal representative.
Plan of Correction:	In respect to the specific resident/situation cited: ISP was signed by Resident 6 RP on June 10,2024. In respect to how the facility will identify residents/situations with the potential for the identified concern: A 100% Audit of Resident?s ISP signature by Resident or legal representative will be conducted. With respect to what systemic measures have been put into place to address the stated concern: A periodic audit of Resident?s ISP?s for Resident or legal representative signature will be conducted by the Director of Clinical Services in addition to our quarterly audits.
Standard #:	22VAC40-73-720-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the written Do not resuscitate (DNR) orders were included in the individualized service plan (ISP). Evidence: 1. Resident 9 has a signed DNR in place dated 01/27/2021. His ISP, dated 12/05/2023, indicates his code status as DNR, but it is not listed on resident 9s ISP. 2. Staff 9 confirmed that the DNR is not listed on resident 9s ISP. 3. Staff 9 confirmed that resident 9 has a valid DNR in his record.
Plan of Correction:	In respect to the specific resident/situation cited: ISP was updated with DNR on June 6, 2024. In respect to how the facility will identify residents/situations with the potential for the identified concern: A 100% Audit of Resident?s with DNR orders ISP?s will be conducted to ensure DNR is on ISP. With respect to what systemic measures have been put into place to address the stated concern: A periodic audit of Resident?s with DNR status ISP?s will be conducted by the Director of Clinical Services in addition to our quarterly audits.