VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arbor Terrace Sudley Manor
7750 Garner Drive
Manassas, VA 20109
(703) 392-9797

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: March 29, 2022

Complaint Related: No

Areas Reviewed:

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

Date of Inspection: March 29 and 31, 2022 Type of Inspection: Monitoring 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 70 Number of records reviewed and interviews conducted- 4 resident records and 4 staff records, 6 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. 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 measure(s). The residents were observed during activities. The Licensing Inspector reviewed fire drills, dieticians report, resident council minutes, menus and health care oversight.

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, it was determined that there was no coordinated plan of care documented on the Individualized Service Plan (ISP) between the facility and the Hospice agency for residents in care. Evidence: Resident B and C have no documentation on the ISP for a coordinated plan of care between the facility staff and the Hospice agency as required.
Plan of Correction:	All Hospice residents will have documentation on the ISP to indicate which tasks facility staff and Hospice agency staff will perform for the residents.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, it was determined that the facility failed to update an Individualized Service Plan (ISP) to indicate a change in condition as required. Evidence: Resident Cs ISP had no documentation to reflect the wound care the resident was receiving.
Plan of Correction:	All ISPs will have the correct documentation to reflect any changes in condition for a resident in care. The nursing staff will audit resident records to ensure compliance.
Standard #:	22VAC40-73-990-B
Description:	Based on facility records review and staff interview, it was determined that the facility failed to review the plan for resident emergencies with staff as required. Evidence: There was no documentation of a review of the plan for resident emergencies with staff every six months as required. The last review was dated August 17, 2021 for a drill. There was no subsequent documentation for all staff.
Plan of Correction:	All facility staff will review the plan for resident emergencies as required. All documentation will be up to date.