VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greenspring Village
7470 Spring Village Dr
Springfield, VA 22150
(703) 923-4663

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: Dec. 16, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 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. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

Please update the posted resident rights to include the Regional Licensing Administrator ? Sharae Henderson ? 804-629-3479 and ensure the current staff person in charge is posted conspicuously.

Comments:

An unannounced renewal inspection was conducted on 12/16/2022. At the time of entrance 158 residents were in care. The sample size consisted of ten resident records, four staff records and two individual interviews. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection conducted on 11/19/2020. Residents were observed eating breakfast and engaging in activities. Medication administration was reviewed. An exit meeting was 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-A
Description:	Based on documentation review and interview the facility failed to ensure that the facility have staff adequate in knowledge, skills and abilities to meet the residents? needs. Evidence: Upon Licensing Inspector?s arrival a private duty aide was observed feeding Resident #5. The facility was not aware that the resident had employed a private duty aid or that the aide was in the building and providing services. Throughout breakfast various staff employed by the facility did not question who this person was providing services in the dining room.
Plan of Correction:	1. Resident #5 ISP was updated to reflect use of PDA 2. Education will be provided to families via electronic newsletter on the need to inform the facility when PDA is contracted. 3. Re-education will be provided to nursing staff on the need to report unknown persons providing services to residents in Garden Ridge and escalate to manager as appropriate. 4. NHA or designee will audit PDA?s in facility monthly x 3 to ensure that residents need for PDAs is reflected in the ISP. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee for review and further action as may be required.
Standard #:	22VAC40-73-320-A
Description:	Based on documentation review the facility failed to ensure that within 30 days prior to admission a person shall have a physical exam by an independent physician. Evidence: Resident #2?s most recent physical dated 5/4/2022 does not include the resident?s height. Significant medical history and general physical condition, allergies, diagnosis, and recommendations for care are noted as ?see attached?. There is not a document attached. The physical does not assess the resident?s medication administration skill. Resident #5?s most recent physical dated 9/30/2020 does not include the resident?s height, weight and blood pressure. General physical condition, diagnosis, and recommendations for care are noted as ?see attached?. There is not a document attached.
Plan of Correction:	1. Resident #2 and Resident #5 most recent physical examination record that included all required information was updated 2. Education will be provided to medical practitioners on the need to use VDSS H&P form and the need to complete the form in its entirety. 3. NHA/designee will audit new admissions monthly x 3 months to ensure proper use and completion VDSS H&P form. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee for review and further action as may be required.
Standard #:	22VAC40-73-440-D
Description:	Based on documentation review the facility failed to ensure the UAI was completed accurately. Evidence: Resident #5?s most recent UAI dated 9/2/2022 assesses the resident as independent in eating. The resident was observed requiring assistance eating and resident?s most recent ISP indicates that the resident requires assistance.
Plan of Correction:	1. Resident #5 UAI was updated to reflect current care needs 2. Re-education will be provided to ALM/WM to ensure that resident care needs are reflected accurately on the UAI. 3. DON or designee will audit 5 UAIs a week in Memory Care/Assisted Living x 4 weeks, then monthly x 2 months to ensure that resident care needs are being documented in accordance to their needs as outlined in the resident UAI. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee for review and further action as may be required.
Standard #:	22VAC40-73-450-A
Description:	Based on documentation review the facility failed to ensure that on or with seven days prior to the day of admission a preliminary care plan is developed. Evidence: Resident #1 was admitted to the facility on 11/1/2022. There was not a service plan in the resident record.
Plan of Correction:	1. Resident #1 ISP was created 2. An audit of current residents will be conducted to ensure that all current residents have a completed ISP on record. 3. Re-education will be provided to ALM/WM to ensure that ISP is completed to reflect the resident care needs in accordance with state regulation. 4. NHA or designee will audit 5 ISP/UAIs a week in Memory Care/Assisted Living x 4 weeks, then monthly x 2 months to ensure that resident care needs are accurately reflected in the ISP and include all components. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee for review and further action as may be required.
Standard #:	22VAC40-73-450-C
Description:	Based on documentation review facility failed to ensure that all the components of the ISP are included. Evidence: The model form currently used for the service plan does not include the date the need was identified, when and where the services will be provided, specific staff to perform service and the time frame for expected completion.
Plan of Correction:	1. No specific resident cited 2. Re-education will be provided to ALM/WM to ensure that ISP will reflect resident care needs in all components including when the needs were identified, when and where the services will be provided and specific staff to perform services. 3. NHA or designee will audit 5 ISP/UAIs a week in Memory Care/Assisted Living x 4 weeks, then monthly x 2 months to ensure that resident care needs are accurately reflected in the ISP and include all components. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee for review and further action as may be required.