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 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION

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: 3:30 PM to 5:30 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 05/29/2024 regarding allegations in the area(s) of: Resident Care & Related Services. 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on facility record review, the facility failed to ensure compliance with the facility?s own policies and procedures. Evidence: 1. Staff 1 provided the facilities Incident/Accident policy created on 09/19/2006 with the latest revision on 09/2023. 2. On Page, item eight (8) reads ?When appropriate, the Resident Care Manager and/or Executive Director should report the Incident/Accident occurrence to the respective State Licensing Agency within the guideline set forth by the Licensing Agency, via phone call and/or email briefly describing the event. 3. Staff 1 confirmed they did not create or submit an incident report to licensing within the guidelines set forth by the licensing agency or the facility?s own policy. 4. Staff 1 provided the Theft and Loss policy created on 07/20/2017. 5. On page 2, item six (6) reads ?Waltonwood has no tolerance for individuals that take items from our residents, other associates, or our community without permission.? 6. Item six (6) goes on to further state in section B ?anyone caught stealing will be prosecuted to the fullest extent of the law.? 7. Staff 1 confirmed that the missing item from Resident 1?s room was located by police at the home of Staff 3. 8. In an email from Staff 2 to Resident 1?s POA, Staff 2 stated ?We always let the residents know that they would need to call the police.? 9. Staff 1 and 2 confirmed that they contacted police to locate the item per the family?s request but declined to press charges and told Resident 1?s POA and Care Manager that it was the resident and family?s responsibility to press charges. 10. On page 2, item eight (8) reads ?The results of any theft investigation will shall be reported in writing to the resident. Documentation shall be maintained for three [3] years regarding items that were reported missing and resulting actions that were taken.? 11. Staff 1 confirmed they did not complete any written documentation or incident report for this investigation.
Plan of Correction:	Internal policy is under review to ensure compliance with 40.A. We will act in compliance with the verbiage presented within our own internal policies and procedures.
Standard #:	22VAC40-73-70-C
Complaint related:	No
Description:	Based on facility record review and staff interview, the facility failed to ensure that a written report of each incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident was submitted to the regional licensing office. Evidence: 1. On the dates of May 24th, 2024, Resident 1 had reported a stolen item and the item was found by police on May 25th, 2024 in the private home of Staff 3. 2. Staff 1 confirmed that they verbally called Adult Protective Services and did not submit a written report to the regional licensing office.
Plan of Correction:	We will ensure written communication of incidents pertaining to matters consistent in 70.C are communicated timely to the regional licensing office.
Standard #:	22VAC40-73-550-G
Complaint related:	No
Description:	Based on staff record review and staff interview, the facility failed to ensure that the rights and responsibilities or residents in assisted living facilities was reviewed annually with each staff person. Evidence: 1. Staff 3, hired on 01/10/2023, completed the resident rights training on 04/15/2023. 2. Staff 3?s record did not contain an updated review of the residents right training; however, the training log indicated a due date of 06/30/2024. 3. Staff 1 confirmed Staff 3 was scheduled to take the training prior to 06/30/2024.
Plan of Correction:	We will audit our Relias logs for Resident Rights training to ensure that annual training timelines are compliant with 550.G
Standard #:	22VAC40-73-740-D
Complaint related:	Yes
Description:	Based on facility record review and staff interview, the facility failed to ensure that the results of an investigation for missing items were provided to the resident in writing. Evidence: 1. On May 24, 2024, Resident 1 notified the facility that their wallet was missing. 2. On May 24, 2024, the facility reached out to Resident 1?s legal representative to notify of the missing item. 3. Resident 1?s legal representative had installed a tracking device. 4. Staff 2 contacted the police with the information provided by the legal representative. 5. The police located the item in the private household of Staff 1 on May 25, 2024. 6. The Licensing Inspector requested the incident report and/or the documentation of the incident. 7. Staff 1 confirmed that they verbally spoke to the both the legal representatives, the police, and Adult Protective Services. 8. Staff 1 confirmed they did not complete any written documentation or incident report for this investigation.
Plan of Correction:	We will ensure communication of incidents pertaining to matters consistent in 740.D are communicated timely to the resident in writing.