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: June 17, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/17/2024 Time In: 10:38 AM Time Out: 2:11 PM 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: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI toured the facility and observed residents smoking in the courtyard, sitting in the common areas, interacting while eating lunch, interacting with staff, and leaving for activities outside of the community. Additional Comments/Discussion: 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-620-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that upon receipt of recommendations noted by a dietitian or nutritionist; the administrator dietician, or nutritionist shall report them to the resident?s physician. Documentation of the report shall be maintained in the resident?s record. Evidence: 1. Resident 1?s dietician report (completed 03/24/2024) states a calorie-controlled diet and thin liquid diet. 2. No documentation was present in Resident 1?s record regarding action taken to recommendation in dietician report. 3. On 06/17/2024, LI interviewed Staff 4 confirmed that the documentation was not present in Resident 1?s record.
Plan of Correction:	What did you do to fix this specific violation? 1. ISP updated for this resident by Resident Service Manager to include dietician?s recommendations. 2. Director of Resident Services to review all ISPs to ensure that dietary recommendations from dietician/nutritionist are included in the ISPs. 3. Director of Nursing will review that all primary physicians that has a resident at Mary Marshall that have a dietary recommendation are notified. What steps are you going to implement to ensure future compliance? 1. All future dietary recommendations to be reviewed by Director of Nursing and Director of Resident Services. 2. Director of Nursing or Charge LPN will forward future dietary recommendations to the resident?s physician and document when it was sent. 3. Resident Service Managers will ensure that dietary recommendations are reflected on the ISP for each resident under section: Health and Nutrition. Date of the recommendation will also be included. What measures will be put in place to monitor compliance? 1. Prior to signing off on the final ISP, Director of Resident Services will check to ensure any dietary recommendations are included. 2. Director of Nursing will ensure that resident?s physician are notified within 3-5 days of receiving a dietary recommendation providing evidence that it was given to the physician.
Standard #:	22VAC40-73-870-A
Description:	Based on LI observation and staff interview, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 06/17/2024, LI observed boxes stacked against the hallway of the second floor. 2. On 06/17/2024, during a facility tour, Staff 5 confirmed that boxes were stacked in the hallway. 3. On 06/17/2024, LI observed a fan against the wall with an unsecured plug laying in the middle of the lobby floor.
Plan of Correction:	What did you do to fix this specific violation? 1. Boxes were immediately removed the next day to clear clutter on the second floor. 2. Completed a walk through to ensure no clutter and boxes were in the hallways but in storage closets or in another appropriate place. 3. Immediately removed on the next day the fan that was against the wall that has an unsecured plug and placed it in an appropriate area. What steps are you going to implement to ensure future compliance? 1. Boxes that are being delivered will need to be moved to an appropriate area that will not cause clutter or block walkways. 2. Trained all staff to be educated on ensuring walkways are safe and free of clutter. Any issues should be reported to Maintenance Director and Executive Director immediately to address. What measures will be put in place to monitor compliance? 1. Maintenance Director with the help of Executive Director will look at all storage spaces to see where items can be stored. Especially when boxes of supplies are being delivered. 2. Maintenance Director and/or Maintenance Assistant will complete rounds during the day to ensure walkways are clear and appliances are securely plugged or put away when not in use. 3. Appliances not in use should be put away. What measures will be put in place to monitor compliance? 1. Maintenance Director with the help of Executive Director will look at all storage spaces to see where items can be stored. Especially when boxes of supplies are being delivered. 2. Maintenance Director and/or Maintenance Assistant will complete rounds during the day to ensure walkways are clear and appliances are securely plugged or put away when not in use.
Standard #:	22VAC40-73-970-A
Description:	Based on facility record review and staff interview, the facility failed to ensure that the fire and emergency evacuation drill frequency and participation were in accordance with the current edition of the Virginia Statewide Fire Prevention Code. Evidence: 1. A fire drill was not conducted in the month of May 2024. 2. On 06/17/2024, LI interviewed Staff 6 confirmed that a fire drill was not conducted in May.
Plan of Correction:	What did you do to fix this specific violation? 1. Provided training and education to Maintenance Director on the Virginia Fire Prevention codes around fire drills. will ensure that a fire drill is conducted every month and documented that it was completed. 2. Reviewed tracking tool to alert Maintenance Director that a fire drill needs to be completed and documented if not done by the 15th of the month. What steps are you going to implement to ensure future compliance? 1. All fire drill reports need to be signed off by Executive Director or designee each month by the 5th of the following month. What measures will be put in place to monitor compliance? 1. Executive Director will document each month that a fire drill was conducted on facility monthly reports to ensure a fire drill has not been missed. 2. If a fire drill has not been conducted by the 15th of the month, Executive Director will instruct Maintenance Director to discreetly provide a date of when fire drill will occur to only the Executive Director.