VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ashby Ponds, Inc.
21160 Maple Branch Terrace
Ashburn, VA 20147
(571) 291-6210

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Aug. 27, 2024 and Aug. 28, 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 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

Technical Assistance:

Documentation was discussed with the provider.

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: 8/27/24 (8:25 AM - 5:50 PM), 8/28/24 (9:25 AM - 7:30 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: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Six Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meals, medication administration, activities, background check documentation 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observation and interview, it was determined that the facility did not ensure that a listing, of all staff that are certified in first aid or CPR, was posted in an area accessible to all staff at all times. Evidence: 1. No facility listing of staff with current certifications in First Aid/CPR was observed. 2. Facility staff reported that a posting was not present, at the time the inspection was initiated.
Plan of Correction:	A listing of all the staff certified in First Aid or CPR was posted in the nurse station of each neighborhood as soon as the issue was identified. Each direct care staff member at Ashby Ponds maintains current certification in first aid as it was confirmed during the inspection.
Standard #:	22VAC40-73-290-B
Description:	Based on observation and documentation, it was determined that the facility did not ensure that the name of the on-site person in charge is posted in a place that is conspicuous to the residents and the public. Evidence: 1. The name of the current on-site person in charge was not posted, at the time the inspection was initiated. 2. A posting that listed the staff members with management/supervisory authority was present, but the posting did not specify the current on-site person in charge.
Plan of Correction:	Onsite person in charge was immediately posted at main entrance, a place conspicuous to the resident and public.
Standard #:	22VAC40-73-560-E
Description:	Based on observation and interview, it was determined that the facility did not ensure that resident records are kept in a locked area. Evidence: 1. During the building walkthrough (8/27/24), at approximately 8:48 AM, the second-floor staff office was observed to be open and unattended. 2. Resident records are kept on the shelves in the staff office. 3. Staff #4 was conducting the tour and confirmed that the room was unlocked/unattended.
Plan of Correction:	The second floor staff office door was closed as during the building walkthrough on 8/27/24. All other staff office doors were confirmed to be closed and protecting resident records. Department Manager or designee educated staff working on 8/27/24 regarding resident records being kept in a locked area. Education will continue.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, it was determined that the facility did not ensure that medications are administered in accordance with the physician's instructions. Evidence: 1. Resident #3's Amlodipine order, dated 5/21/24, calls for the medication to be held when Resident #3's SBP is less than 110, or Pulse less than 60. 2. Resident #3's Amlodipine was documented as administered on the medication administration (MAR) on 8/1/24 (SBP = 103, Pulse = 72) and 8/3/24 (SBP = 103, Pulse = 74).
Plan of Correction:	Resident #3 did not present with any adverse reaction from the medication that was administered. Staff that administered the medications were educated on the five rights of medication administration including following physician?s instructions. Audits of residents taking BP medications with parameters were conducted and no other resident was identified as affected.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, it was determined that the facility did not ensure that the medication administration record (MAR) includes all of the required information. Evidence: 1. Resident #4's record contained an order for sliding scale insulin that indicates: For BS 150-200: Give 1 Unit SQ; For BS 201-250: Give 2 Units SQ; For BS 251-300: Give 3 Units SQ; For BS 301-350: Give 4 Units SQ; For BS 351-400: Give 5 Units SQ; For BS 401-450: Give 6 Units SQ; 2. Resident #4's August MAR contained documentation that sliding scale insulin was administered three times daily, with the exception of: 8/2/24 (8 AM), 8/7/24 (8 AM and noon), 8/9/24 (8 AM and noon), 8/11/24 (8 AM), 8/17/24 (8 AM), 8/22/24 (8 AM), 8/23/24 (5 PM), 8/24/24 (8 AM), 8/26/24 (8AM), and 8/27/24 (8 AM, noon, and 5PM). 3. When Resident #4's sliding scale insulin was documented as administered, the amount of insulin given was not documented on the MAR.
Plan of Correction:	Order was re-entered on 8/29/24 for Resident #4 to include blood sugar and insulin units. Audit of current residents receiving sliding scale was conducted and 2 other residents were identified as affected. Sliding scale orders were corrected for the 2 residents to include insulin units. License nursing staff were educated on proper order transcription in the eMAR to include blood sugar and insulin units of all sliding scale.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, it was determined that the facility did not ensure that PRN medications are available and properly stored at the facility. Evidence: 1. PRN Acetaminophen 500mg, ordered for Resident #3, was not present at the time of the medication area inspection. 2. Staff #5 and Staff #6 confirmed that the Resident #3's PRN Acetaminophen was not present, at the time of the medication area inspection.
Plan of Correction:	PRN Tylenol medication was re-filled from the pharmacy and delivered to facility on 8/29/24 for Resident #3. Audit of all residents receiving PRN medications was conducted and no other residents were identified as affected. Staff were re-educated to pro-actively refill medications with 7 doses left.
Standard #:	22VAC40-73-970-A
Description:	Based on documentation, it was determined that the facility did not ensure that fire drills were conducted in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. Facility staff reported that there are three shifts at the facility. 2. No documentation was provided to indicate that a fire drill, during the 11PM - 7 AM shift, was conducted within the quarter. 3. The most recent documented fire drill, conducted during the 11PM - 7 AM shift, was conducted in March 2024.
Plan of Correction:	A fire drill was conducted during the night shift of 8/28/2024. Security Manager and/or designee will provide in service education to ensure fire and emergency drills required for each shift in a quarter are not conducted in the same month. Date of compliance 10/4/2024. Security Manager and/or designee will schedule drills to be conducted during each shift, every quarter.