VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Johnson Center at Falcons Landing
20535 Earhart Place
Potomac falls, VA 20165
(703) 404-5201

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Sept. 23, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 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

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: 9/23/24 (9:15 AM ? 4:30 PM) 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: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of staff records reviewed: Two Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meal, medication administration, activity, background checks of staff hired since the last inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial 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 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility did not ensure that each direct care staff member maintains current certification in first aid from the 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 first aid or include adult first aid. Each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. Evidence: 1. The record of Staff #2 (hired 7/15/24) did not contain current certification in first aid. 2. No documentation of current first aid certification for Staff #2, was provided during the inspection. 3. Staff #2's record contained a copy of current CNA and CPR certification. No documentation, was included in Staff #2?s record, to indicate that the staff member is a registered nurse, licensed practical nurse, or currently certified emergency medical technician, first responder, or paramedic.
Plan of Correction:	1. No residents were affected by this alleged deficient practice. 2. Staff #2 provided facility with current first aid certification on 9/26/24. 100% audit of staff credentials completed. No other issues noted. 3. All licensed staff were re-educated on providing updated first aid credentials as required by licensure. 4. The LPN nurse coordinator was re-educated on the importance of maintaining up to date first aid certification logs for assisted living staff members. 5. The LPN nurse coordinator will audit first aid certification logs monthly x3 months to ensure compliance. Findings will be discussed in the quarterly quality assurance report.
Standard #:	22VAC40-73-560-E
Description:	Based on observation, the facility did not ensure that resident records are kept in a locked area. Evidence: 1. During the building walkthrough, at approximately 9:28 AM, the nursing office was observed to be unlocked and unattended. 2. Resident records were contained in a cabinet in the nursing office. 3. The cabinet, containing the resident records, was not locked.
Plan of Correction:	1. No residents were affected by this alleged deficient practice. 2. The cabinet containing resident records was locked. The nursing office door was locked. 3. All licensed staff were re-educated on ensuring the resident records are kept in a secure locked area. 4. The LPN nurse coordinator was re-educated on the importance of ensuring the nursing office is locked and the cabinet containing the resident records is secured. 5. The LPN nurse coordinator will audit compliance with record storage weekly x 4 weeks and then monthly x3 months to ensure compliance. Findings will be discussed in the quarterly quality assurance report.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility did not ensure that physician orders for dietary supplements include the strength. Evidence: 1. Resident #1's physician?s orders were reviewed during the inspection. 2. Resident #1's order for Vitamin D3, dated 5/9/24, did not include the strength of the supplement.
Plan of Correction:	1. No residents were affected by this alleged deficient practice. 2. On 9/25/24, the strength of the vitamin D3 supplement was added. All other resident charts containing orders for supplements were reviewed for strength. No other issues were noted. 3. All licensed staff were re-educated on notating strength of supplements when transcribing physician orders. 4. The LPN nurse coordinator will audit all new physician orders for supplements to ensure compliance with notating strength, weekly x 4 then monthly x3 months to ensure compliance. Findings will be discussed in the quarterly quality assurance report.
Standard #:	22VAC40-73-650-E
Description:	Based on record review, the facility did not ensure that the resident record contains the physician's signed written order or a dated notation of the physician?s oral order. Evidence: 1. Resident #1's medication administration record (MAR) included Acetaminophen 325mg tablets with a start date of 7/26/24. 2. The physician's order, for Resident #1's Acetaminophen 325mg tablets, was not included in the resident record at the time of the record review.
Plan of Correction:	1. No residents were affected by this alleged deficient practice. 2. The physicians order for Resident #1's Acetaminophen was obtained and included in the resident record on 9/25/24. 3. All licensed staff were re-educated on transcribing physicians oral orders to the medical record when obtained. 4. The LPN nurse coordinator will audit physician orders weekly x 4 weeks then monthly x3 months to ensure compliance. Findings will be discussed in the quarterly quality assurance report.