VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cobbdale Assisted Living (Fairfax Co)
3503 Burrows Avenue
Fairfax, VA 22030
(571) 414-1850

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Feb. 4, 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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.

Technical Assistance:

Licensing Inspector advised administration of the changes made to Standard 50-A and that the facility's disclosure statement would need to be updated to reflect the changes.

Comments:

An unannounced monitoring study was conducted on 2/4/2020. At the time of entrance eight residents were in care. The sample size consisted of four resident records, three staff records, and one individual interview. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 1/29/19 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including walking group and kicking an exercise ball. Medication administration was observed. Possible violations were discussed at the exit interview. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based upon a review of records, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it and the risk assessment shall be no older than 30 days. Based upon a review of records the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #2 was hired on 11/14/19 and the tuberculosis assessment in the record was dated 10/23/17. Staff #3 was hired on 9/9/19. The tuberculosis assessment in the file was dated 9/9/19 but did not indicate the staff member was free of tuberculosis in a communicable form. Staff #1 was hired 9/10/17. The tuberculosis assessment in the file had a date of 3/2018.
Plan of Correction:	For staff members #1, #2, and #3 a current tuberculosis assessment (TB) form will be collected. The assessment will be no older than 30 days. The administrator will ensure these new assessments will be added to the employee's files.
Standard #:	22VAC40-73-260-A
Description:	Based upon a review of records, the facility failed to ensure that each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years. Evidence: The records for Staff #2 and Staff #3 did not include current certification in first aid.
Plan of Correction:	For staff members #2 and #3, a current CPR certification card will be obtained for each employee. The administrator will ensure that the new certification cards will be added to the employee's files.