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: Nov. 7, 2024

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 Background Checks for Assisted Living Facilities Sworn Statement

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: 11/7/2024 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: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents eating meals and participating in activity programs. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-140-E
Description:	Based on staff record review and staff interview, the facility failed to have an administrator licensed as an assisted living facility administrator on record. Evidence: 1. Staff 1 stated Staff 3?s ALFA license expired on 3/31/2022. 2. The department?s regional licensing office was not informed of the appointment of an acting administrator.
Plan of Correction:	Reinstatement and Renewal Requirements were completed and submitted to DHP VA. Philip Calubaquib?s reinstatement is ?pending?. Melissa Weatherholtz license is now reinstated, renewed and active.
Standard #:	22VAC40-73-150-B-1
Description:	Based on staff interview, the facility failed to notify the department?s regional licensing office in writing within 14 days of a change in a facility?s administrator, including resignation of an administrator, appointment of an acting administrator, including, and appointment of a new administrator, except that the time period for notification may differ as specified in subdivision 2 of this subsection. Evidence: 1. Staff 1 informed me that the administrator on file?s Assisted Living Facility Administrator (ALFA) license expired on 3/31/2022 and she was not aware until recently. 2. Licensing inspector confirmed by license lookup on Department of Health Profession website that Staff 3?s ALF license expired on 3/31/2022
Plan of Correction:	Both ALFA?s licenses expired on 3/31/22. However, DHP.Virginia.gov renewal link was active until November 2024. We were able to renew and pay every year until November 2024 and was just now informed that our licenses were already expired. Reinstatement is in process for Philip Calubaquib. Melissa Weatherholtz license is already reinstated and renewed
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: Staff 1 stated `I don?t think I have it? and was never supplied to the licensing inspector during the time of inspection.
Plan of Correction:	The facility will check with the Registry of Sex Offenders on the State Police Website before admitting a new resident if potential resident is a registered sex offender.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed develop an Individualized Service Plan (ISP) that identified the needs and dates identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning if appropriate; and (vi) other sources. Evidence: 1. Resident 1 had a Fall Risk Assessment Tool completed on 12/14/2023 that assessed the resident as `High Fall Risk?. 2. The ISP developed on 8/25/2024 did not list interventions to prevent or reduce falls.
Plan of Correction:	Staff I will develop an ISP that will identify the needs and dates identified on the UAI. Resident I had a High Risk Fall Assessment Tool on 12/14/23. The ISP that was done on 8/25/24 should have had this information. Any resident assessed with HFR based on the UAI will have the list of interventions to prevent or reduce falls on the ISP.
Standard #:	22VAC40-73-490-A
Description:	Based on facility record review, the facility failed to have a licensed health care professional, practicing within the scope of his professional shall provide healthcare oversight at least every six months. Evidence: 1. The last Health Care Oversight on file was conducted on 2/18/2024. 2. Staff 1 stated the facility employs a part-time nurse.
Plan of Correction:	Health Care oversight will be done quarterly by an LPN who works at the facility part time. Last HCO: 2/18/2024
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review and staff interview, the facility failed to review the rights and responsibilities of residents with the resident or legal representative annually. Evidence: 1. Resident 1 had a review of residents right on file dated 5/30/2023 and Resident 2 did not have an annual resident right review on file within the last year.
Plan of Correction:	The facility will review the rights and responsibilities of residents with the resident or legal representative annually.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to, at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medication administered to residents, including over-the-counter medications and dietary supplements including the date and time given and initials of direct care staff administering the medication. Evidence: 1. Resident 1?s MAR for November 1-6, 2024 did not include dates and time given or the initials of the direct care staff administering the medication for the following medications: Donepezil HCL 5 mg tablet(prescribed 9/19/2018), Vitron-C Tablet (prescribed 5/26/2020), Vitamin B-12 1000 mcg tablet (prescribed 6/3/2021), Vitamin D 2000 unit tablet (prescribed 6/3/2021), and Loratadine 10 g tablet (prescribed 6/3/2021). 2. Resident 2?s MAR for November 1-6, 2024 did not include dates and time given or the initials of the direct care staff administering the medication for the following medications: Tramadol HCL 50 mg tablet (prescribed 10/28/2024, Methenamine HIP 1 gm (prescribed 10/1/2024), Ferrous Sulfate 325 mg tab (prescribed 10/28/2024), Quietiapine FUM 50 mg Tab (prescribed 10/1/2024), Donepezil HCL 10 mg tab (prescribed 10/1/2024), Mirtazapine 15 mg tab (prescribed 9/1/2024).
Plan of Correction:	The MAR used in the facility will be changed. Each medicine will have its own MAR, initial of the Med-aide, dosages, and its indication/diagnosis for each resident.
Standard #:	22VAC40-73-690-B
Description:	Based on resident record review, the facility failed to, for each resident assessed for assisted living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, shall perform a review every six month of all the medications of the resident. Evidence: 1. The Bi-yearly Review of Resident Medications on file for Resident 1 was not dated. 2. The Bi-yearly Review of Resident Medications on file for Resident 2 was dated 11/3/2022.
Plan of Correction:	The facility will have their LPN perform a review of all medications given to the residents. This will done every 6 months.
Standard #:	22VAC40-73-710-D
Description:	Based on observation and staff interview, the facility failed to keep a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems. Evidence: 1. Licensing inspector observed Resident 1 in bed with bedrails in the up position. 2. Staff 1 stated the staff check on Resident 1 every 30 minutes but did not know they were to documents these checks.
Plan of Correction:	The facility staff check residents using restraints every 30 minutes, but failed to document checks. The staff will now document any unusual occurrences/problems. Resident I?s full bed rail will be reduced to a half bed rail or partial bed rail that will not restrict resident?s freedom of movement
Standard #:	22VAC40-73-950-E
Description:	Based on facility records review, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents and volunteers. Evidence: The last two reviews by staff of emergency preparedness and response plan was conducted on 8/12/2023 and 2/14/2024.
Plan of Correction:	The semi-annual Emergency Preparedness and Response Plan Orientation and Review will be developed and implemented twice a year. 8/14/2024 and 2/14/2025
Standard #:	22VAC40-73-990-B
Description:	Based on facility records review, the facility failed to review the procedures and the plan for resident emergencies with staff every six months and document the review with each staff member. Evidence: The last review by staff on file was conducted on 2/14/2024.
Plan of Correction:	Resident Emergencies & Procedures and Plan will be reviewed with every staff every six months and will be documented. 2/14/2024, 8/14/2024 & 2/14/2025