VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Hills Mt. Vernon
3709 Shannons Green Way
Alexandria, VA 22309
(703) 780-7100

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: March 30, 2023

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 refer to the DSS website for the most recent Health & Physical Report, TB Screening and Fire Drill Report model forms. Encourage the Maintenance Director, Administrator and corporate office to complete a formal walkthrough of the facility and note furniture that is showing wear, walls that require painting and carpet that requires cleaning or replacement. Please update the posted resident rights to reflect the current Licensing Administrator ? Sharae Henderson, 804-629-3479

Comments:

Type of inspection: Renewal An unannounced renewal inspection was conducted on 3/30/2023. At the time of entrance 74 residents were in care. The sample size consisted of ten resident records, five staff records and three 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 3/8/2022. Residents were observed eating breakfast and lunch and engaging in activities including current events, exercise and sing-along. Medication administration was observed. 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. Wthin 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 Iynette.storr@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-A
Description:	Facility failed to ensure that there are staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. Evidence: Upon Licensing Inspector?s arrival in the memory care environment six residents were observed in the dining room having breakfast. One staff was present with his back turned to the residents. The residents were not attended to while eating or provided any social interaction for 10 minutes. During the observed lunch in the memory care environment, 12 residents were in the dining room being seated for lunch with one staff person providing care. The residents that were seated in the dining room required a higher level of supervision due to wandering behaviors, assistance with eating and socialization needs.
Plan of Correction:	All associates are required to complete training upon hire and ongoing to ensure person centered care is provided to our residents. In response to the inspector?s observations, a mandatory in-service for all associates will occur no later than April 19, 2023.