VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mary Marshall Assisted Living Residence
2000 5th Street, South
Arlington, VA 22204
(571) 527-5002

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Feb. 11, 2020

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 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.

Comments:

An unannounced monitoring inspection was conducted on 2/11/2020. At the time of entrance 52 residents were in care. The sample size consisted of eight resident records and four staff records with two individual interviews.Criminal background checks for staff hired since last inspection were also reviewed. Resident and staff records and other documentation were reviewed. Residents were observed eating breakfast. Medication administration was observed. No violations cited today and exit interview held. If you have any questions about this inspection please contact Tammy Pruitt by emailing tammy.pruitt@dss.virginia.gov or calling 703-314-0604.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on documentation review facility failed to ensure staff record contained all required information. As evidenced by: Staff #2's staff record does not contain a copy of a current medication tech certification or job description.
Plan of Correction:	Job description will be printed by Business Office Manager, signed by employee and placed in personnel file. Employee will have 10 business days to submit paper work and fees to the Virginia Board of Nursing for the transfer of med tech license from Maryland to Virginia. Executive Director will do audit of all personnel files to assure that all licensing requirements are included in each personnel file.
Standard #:	22VAC40-73-320-A
Description:	Based on documentation review, facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the information stated in the Standards and Regulations. As evidenced by: Residents number 2,3,4,5 and 6 all have the old History and Physical (H&P) form which is missing a new requirment of medication administration. Resident's #4's H&P dated 4/9/19 stated the need for skilled nursing facility which is a prohibitive condition. Resident #5's H&P dated 4/9/19 does not have the prohibitive condition page.
Plan of Correction:	New History and Physical form will be printed from the Division of Licensing Programs website by Director of Nursing. Beginning immediately, all annual physicals will be documented on new form. All old forms will be destroyed. The doctors of residents who had (1) missing page of prohibitive conditions and (2) ?yes? checked for skilled nursing care for the administration of medications will be contacted and the form corrected to comply with current Assisted Living standards.
Standard #:	22VAC40-73-490-A
Description:	Based on documentation review the facility failed to update the Healthcare Oversight form. The form they are currently using does contain the new required information.
Plan of Correction:	The Director of Nursing will print the new HealthCare Oversight form from the Division of Licensing Programs website. The new form will be used for the next quarterly oversight report (Jan ? Mar 2020), and ongoing.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure Medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. As evidenced by: Resident #4 had an outdated PRN Ibuprofen 400mg expired date 10/12/19. Resident #5's Ibuprofen 200mg expired 1/14/2020. Resident #4's PRN Magnesium Citriate Solution was not available. Resident #5's PRN Robitussin DM 10mg/5ml and refresh tears 0.5% were not available.
Plan of Correction:	Director of Nursing will distribute a list of all PRN medications, printed from Point Click Care, to assigned staff every two weeks. The list will be divided by floor, with one staff assigned to audit the cart on a specific floor. Staff will document the number of pills and the expiration date for each PRN medication, and submit to the Director of Nursing for review, within one week. Any expired medication or any medication that is on the cart without an active order will be removed from the cart for the LPN/DON to re-order. Director of Nursing will maintain a tracking record.
Standard #:	22VAC40-73-870-A
Description:	Based on observation the facility failed to ensure, the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. As evidenced by: The bathroom by the nurses station has paint that is peeling and bubbling. Additionally, there is dirt build up around the baseboards.
Plan of Correction:	The Director of Environmental Services will do a physical inspection of all public bathrooms. Any peeling and/or bubbling paint will be scraped, repaired, sanded and painted as needed, and all bathrooms will be thoroughly cleaned eliminating any built up dirt and grime.