VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Years and More
13114 Canova Drive
Manassas, VA 20112-7840
(703) 407-9492

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Oct. 26, 2022

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness

Comments:

Date of Inspection: October 26m 2022 and November 3, 2022 Type of Inspection: Renewal inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 5 Number of records reviewed and interviews conducted- 7 records, 2 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). The completed corrective action needs to be in the licensing office by November 17, 2022

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, it was determined that the facility failed to obtain admitting documentation as required. Evidence: Res C had no initial tuberculosis risk assessment completed as required.
Plan of Correction:	Golden Years and More, ALF has all the admitting documentation as required prior to admission.
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review and staff interview, it was determined that the facility failed to develop a preliminary plan of care when the resident was admitted to facility. Evidence: Res C was admitted on 10/21/2022 and had no documented preliminary plan of care on file at time of inspection on 10/26/2022.
Plan of Correction:	A preliminary plan of care will be developed prior to admission to Golden Years and More.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, it was determined that the facility failed to update the Individualized Service Plan to indicate a change in condition as required. Evidence: Res B's Individualized Service Plan did not include Home Health Physical Therapy services.
Plan of Correction:	The Individualized Service Plan has been updated. Changes in the condition of the resident have been addressed to the Individualized Service Plan.
Standard #:	22VAC40-73-620-A
Description:	Based on record review and staff interview, it was determined that the facility failed to complete a dietary review of special diets every six months. Evidence: The last dietary review on file was conducted on 11/15/21.
Plan of Correction:	The dietician reviewed and ultimately submitted the semi-annual review for November 2022 with her Dietetic Registration.
Standard #:	22VAC40-73-690-B
Description:	Based on record review and staff interview, it was determined that the facility failed to complete a Medication Review every six months. Evidence: No Medication Review was documented within the last six months.
Plan of Correction:	A medication review will be conducted by a licensed pharmacist from Manassas Pharmacy every six months.
Standard #:	22VAC40-73-950-E
Description:	Based on record review and staff interview, it was determined that the facility failed to conduct a semi-annual review with staff. Evidence: The last Emergency Preparedness review on file for staff was 2/14/22.
Plan of Correction:	Semi-review will be conducted with staff.
Standard #:	22VAC40-73-990-B
Description:	Based on record review and staff interview, it was determined that the facility failed to conduct resident emergencies review/drills with staff every six months. Evidence: The last documented review of resident emergencies with staff was held on 11/7/2021.
Plan of Correction:	Semi-annual review will be held with staff.