VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Beverly Assisted Living
3408 Beverly Drive
Annandale, VA 22003
(571) 308-3793

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: June 17, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Date of the inspection: June 17, 2024, 11:30-14:30. Type of inspection: Complaint A complaint was received by the Virginia Department of Social Services, Division of Licensing on June 13, 2024, regarding allegations in the area of : Insufficient staffing and Medication Aid training. 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: 8. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2. Number of staff records reviewed: 5 Number of interviews conducted with residents: 1. Number of interviews conducted with staff: 2. Observations by licensing inspector: Meals, Activities, Medication Pass An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did NOT support the allegations of noncompliance with standard(s) or law. However, violations not related to the complaint but identified during the course of the investigation can 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397 3017 or by email at Jacquelyn.kabiri@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-190-C
Complaint related:	No
Description:	Based on record review and observation, the facility failed to ensure that the staff in charge were informed of or received training on duties and responsibilities nor were they provided written documentation of such duties and responsibilities. Evidence: 1. On 6/17/2024, a posting was observed in the facility that listed the persons in charge for 6/17/2024. 2. Staff 2?s record was reviewed and the file was absent of any specific training, qualifying staff 2 for the position of staff in charge. 3. Staff 4 stated that staff 2 did not have the required training.
Plan of Correction:	Designated person in charge was informed and trained of the duties and responsibilities and were provided written documentation of such duties and responsibilities.
Standard #:	22VAC40-73-710-C
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that the requirements for restraint usage were met. Evidence: 1. A side rail was observed on the bed of resident 1. After reviewing resident 1?s records, no doctor?s order was on file for a side rail. 2. Side rail was observed in resident 1?s room and a photo was taken.
Plan of Correction:	Physicians order was obtained for the side rail.
Standard #:	22VAC40-90-40-B
Complaint related:	No
Description:	Based on documentation and an interview, the facility failed to obtain a criminal history record report (CHRR) within 30 days of employment. Evidence: 1. The CHRR for staff 1 (hired 3/1/2021) was dated 10/1/2021. As of 6/17/2024, the CHRR was not completed and on file. 2. Staff 4 stated that she was unaware of the CHRR not being completed.
Plan of Correction:	Background check was submitted by certified mail.