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 1, 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 Buildings and Grounds Emergency Preparedness Mixed Population Safe, Secure Environment

Comments:

Date of Inspection: March 1, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@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 60 Number of records reviewed and interviews conducted- 8 records(staff and residents), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: pharmacy review, dietician report, emergency preparedness drills, fire drills, resident emergency drills, and healthcare oversight..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 m

Violations:

Standard #:	22VAC40-73-490-A-2
Description:	Based on facility record review and staff interview, it was determined that the facility failed to have documentation of a healthcare oversight every three months as required. Evidence: The last healthcare oversight was dated January 2023 for the facility.
Plan of Correction:	Healthcare Oversight will be completed by Corporate Registered Nurse quarterly.
Standard #:	22VAC40-73-860-I
Description:	Based on direct observation by the Licensing Inspector, It was determined that the facility failed to store cleaning supplies in a locked area. Evidence: The cleaning carts were not locked as required and the cleaning supplies were loose and unattended while staff completed the assignments for the day.
Plan of Correction:	Cabinets and locks will be installed on all housekeeping carts cabinets. Staff will be in-serviced on appropriate storage of cleaning supplies and carts.
Standard #:	22VAC40-73-870-A
Description:	Based on direct observation by the Licensing Inspector, it was determined that the interior and the exterior of the building was not in good repair. Evidence: There were windows that were broken in the safe, secure unit as well as the staff breakroom. The fencing on the side of the building was down on the ground. The fencing in the secure courtyard was broken along the top. The cleaning carts had broken compartment doors.
Plan of Correction:	Replacement windows ordered and will be installed. Fencing on side of building will be repaired or removed. Lattice on memory care courtyard will be repaired. Cleaning carts compartment doors will be repaired or replaced.
Standard #:	22VAC40-73-880-B
Description:	Based on direct observation by the Licensing Inspector, it was determined that the facility staff was using a portable heating unit that was not approved by the state fire authorities. Evidence: The staff breakroom had an operating portable heater in use at the time of inspection.
Plan of Correction:	The portable heater was removed immediately from the premises. DES will ensure portable heaters are not in use during daily rounds.