VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Waltonwood Ashburn
44145 Russell Branch Parkway
Ashburn, VA 20147
(571) 918-4854

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: June 6, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/06/2024, 5:30 PM to 7:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/31/2024 regarding allegations in the areas of: Building and Grounds, Resident Accommodations and Related Provisions, and Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included a resident room and the building and grounds of the facility. Number of residents present at the facility at the beginning of the inspection: 96 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standards or law were: Resident Care and Related Servies, Resident Accommodations and Related Provisions, and Building and Grounds. A violation notice was issued; any violation(s) not related to the complaints but identified during the course of the investigation can also be found on the violation notice. 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on staff interview, the facility failed to ensure a method of written communication was used as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents. Evidence: 1. The licensing inspector requested the written shift communication logs. 2. Staff 2 stated that instead of the communication logs, they complete ?meet-outs? and ensure the staff review information verbally. Staff 2 confirmed they do not use written communication.
Plan of Correction:	Communication log binder for both assisted living and memory care has been implemented. Will be reviewed and documented by each SIC daily at end of shift. Resident Care Manager and/or Wellness Coordinator will review it weekly for compliance.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. Resident 1?s progress notes indicate a fall on 05/29/2024, 05/26/2024, 05/24/2024, 05/23/2024, 05/17/2024 and multiples falls on 05/19/2024 and 05/16/2024. 2. The last fall assessment was completed with the residents 30-day evaluation on 05/15/2024. 3. Staff 2 confirmed that another fall risk assessment had not been completed for the falls that occurred after 05/15/2024.
Plan of Correction:	Resident Care Manager and/or Wellness Coordinators will review falls within 48 hours to ensure that the required documentation is completed to include a new fall risk assessment and interventions be put into place.
Standard #:	22VAC40-73-660-A-1
Complaint related:	Yes
Description:	Based on direct observation, resident record review, and staff interview, the failed to ensure that medication and dietary supplements administered by the facility were stored in a locked medicine cabinet, contained, or compartment. Evidence: 1. Two licensing inspectors observed a bottle of Extra Strength Tylenol 500 MG in the room of Resident 1 beside the bed on the nightstand. 2. Resident 1 does not have a physician order for Tylenol 500 MG. 3. Upon further inspection, there was a loose Tylenol gel capsule on the floor, and a small white pill was observed on the covers of the bed. 4. Resident 1?s UAI, dated 05/15/2024, lists medication should be administered by professional nursing staff described as RN, LPN, or MT. 5. Staff 2 removed the pills from the floor and bed, as well as the pill bottle from Resident 1?s nightstand. 6. Staff 2 suggested that the bottle of Tylenol may have been dropped off by the legal representative on Tuesday, June 04th, during visitation; however, was unsure how or when the bottle was placed in the resident?s room. 7. Photo evidence taken.
Plan of Correction:	Family/resident letter sent by Executive Director on 7/1/24 requesting that all OTC meds and scheduled meds be kept on the medication cart for all residents who do not self-medicate. All residents who do not self-medicate are required to turn over any medications that they might have in their possession so that they can be placed on the med cart. 6/28/24 ? 7/5/24 Medication administration policy reviewed with med techs on 6/28/24. Policy states that any staff administering medications should remain with resident until meds are taken. Staff will report to RCM/WC any medications observed in resident rooms immediately.
Standard #:	22VAC40-73-680-H
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to document on the medication administration record (MAR) all medications administered to residents at the time of administration. Evidence: 1. Resident 1 has an order for Rytary ER 48.75MG-195MG Cap that states ?Take 2 capsules = (97.5-390MG) by mouth ? own meds ? three times a day for Parkinson?s.? 2. The MAR indicates a dose was missed on 05/11/2024 at 2:00 PM. 3. Staff 2 stated that she interviewed the Medication Aide that was on site that day. The medication aide confirmed the resident received the dose and stated that the medication aide ?must have forgot to log it.?
Plan of Correction:	Med techs in-serviced on medication administration documentation process on 6/28/24 Reviewed medical administration clinical skills check list with med techs. Specifically, ?documentation of medication administration? on 6/28/24. Resident Care Manager or designee will audit weekly for compliance.
Standard #:	22VAC40-73-680-K
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure that all PRN medications include a detailed medication order including the symptoms that indicate the use of medication, the exact dosage, the time frames the medication is to be given, and directions on what to do if symptoms persist. Evidence: 1. Resident 1 has an order for Lorazepam 0.5MG Tablet that states ?Take one table by mouth every 8 hours as needed for anxiety.? 2. Resident 1 has an order for Quetiapine Fumarate 25 MG(D) that states ?Take one tablet by mouth every 8 hours as need for psychosis.? 3. There is no indication of the symptoms that indicate the use of the medication.
Plan of Correction:	Resident charts and med lists audited on 7/12/24. Specific behaviors/symptoms added for PRN medications Physicians and Nurse Practitioners have been asked to specify reasons for PRN medications when orders are written/received by facility. Resident Care Manager or designee will audit weekly for ongoing compliance going forward.
Standard #:	22VAC40-73-750-E
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that the facility had sufficient bed and bath linens in good repair so that residents always have clean waterproof mattress covers when needed. Evidence: 1. Resident 1?s Uniform Assessment Instrument (UAI), dated 05/15/2024, lists the resident as incontinent weekly or more and needing assistance with both bowel and bladder. 2. The UAI indicates that Resident 1 needs assistance with both bowel and bladder. 3. On May 29, Resident 1?s legal representative submitted a complaint to Staff 1 via email regarding the mattress not having a waterproof pad protector. 4. Staff 1 provided photos of the mattress in Resident 1?s room with stains on the mattress, and a no pad protectors. There was a flat sheet on the bed. 5. Staff 1 confirmed that the mattress had been soiled and they had a professional company come to clean the mattress. 6. Two licensing inspectors observed the room and found a fresh feces stain on the sheet of the bed. 7. Staff 2 confirmed the residents? rooms are cleaned weekly by custodial staff and as needed by care staff. 8. The last date that Resident 1?s room was cleaned by custodial staff was 05/31/2024. 9. There was no documentation of cleaning in Resident 1?s room completed by care staff.
Plan of Correction:	Staff will inspect that bed and bath linen in good repair on daily basis during room checks while making resident?s bed. Letter sent to all families requiring use of mattress covers on 7/1/24 Facility has purchased additional mattress covers and linens for emergency use if resident?s linens/mattress cover is soiled.