VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Virginian
9229 Arlington Boulevard
Fairfax, VA 22031
(703) 385-0555

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: June 22, 2022

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

Technical Assistance:

Documentation was discussed with the provider.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/2/22 (9:05 AM ? 7:40 PM) 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: 137 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of interviews conducted with residents: 5 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure the physical examination form, completed within 30 days preceding admission, includes all of the required information. Evidence: The record for Resident #1, admitted 5/25/22, was reviewed during the inspection. Resident #1's record contained a tuberculosis risk assessment, dated 6/10/22. Facility documents included a summary sheet with information about Resident #1?s chest x-ray and PPD that were completed before her admission. The summary sheet did not include the signature of the screeners, nor were the results on a screening form consistent with a tuberculosis screening form published by the Virginia Department of Health. The record for Resident #2, admitted 4/14/22, contained a tuberculosis risk assessment, dated 6/14/22. The tuberculosis risk assessment was not completed within 30 days preceding her admission. Resident #8?s physical examination form, dated 5/13/22, did not include her height or weight. Resident #8?s tuberculosis risk assessment, dated 6/7/22, was not completed within 30 days preceding her admission (5/19/22).
Plan of Correction:	No Resident was harmed by this violation. The Residents' history and physical forms have been reviewed for compliance and missing documentation has been corrected within our progress notes. We have met with the Admissions team to ensure all forms will be completed in a timely manner. Signatures of TB screeners will be included going forward. Admissions staff will ensure that every field of the History and Physical form will be completed, to include height and weight. The Head nurses of Assisted Living and Memory units will perform a final review of these forms prior to admission to ensure compliance. All documentation for new Assisted Living and Memory admissions will be delivered/sent to the Lead nurses of both Assisted Living and Memory, (depending on the level of care) at minimum of three business days prior to admission. The Administrator will be informed of any anomalies.
Standard #:	22VAC40-73-460-D
Description:	Based on documentation and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: Resident #11 eloped from the special care unit on 2/23/22 by walking out of a door that was propped open by contractors. Resident #11 left the building and went approximately 0.3 miles to the home of a friend. Resident #11's ISP, updated 11/2/21, states that the resident needs assistance with transfers and ambulation due to an unsteady gait.
Plan of Correction:	The Residents in question were found unharmed in a short space of time. New alarms on all doors leading out of the Memory unit and all produce audible alarms when pushed. Hourly rounding by the Lead nurse or designee is being performed to ensure attendance and safety. Any anomalies will be immediately reported to the Administrator and Director of the Memory unit. Education to staff about elopement commenced immediately, across all shifts.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that hazardous materials are kept in a locked area. Evidence: Brush on hair remover cream and Systane eye drops were observed in the bathroom of Resident #2 of the memory care unit. Resident #2's record included an assessment of serious cognitive impairment form, dated 4/5/22, that states that she has a serious cognitive impairment with an inability to recognize danger or protect her own safety and welfare.
Plan of Correction:	No Resident was harmed by this violation. An immediate sweep of all rooms was performed by the Head Nurse and Director of the Memory unit to ensure a safe environment. As part of our renovation process, a work order was immediately placed for the remaining under-the-sink cabinets to be secured with safety locks. Conversations with families began immediately to inform them of the seriousness of bringing in liquids and creams for loved ones and they reacted supportively. Letters to families are being sent to explain and confirm this policy. The Director of the Memory unit created an audit form, which will ensure that assigned staff perform daily safety checks. Audit forms will be reviewed by the Director of Memory, who will ensure daily compliance for the next three months.
Standard #:	22VAC40-73-970-A
Description:	Based on documentation, the facility failed to ensure that fire and emergency evacuation drill frequency and participation is in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: The current Virginia Statewide Fire Prevention Code requires fire drills to be conducted quarterly on each shift. Fire drill documentation was requested during the inspection, but no documentation was provided to confirm that fire drills had been conducted in the ALF within the past three months.
Plan of Correction:	No Resident was harmed by this violation. An unannounced drill was held on the day shift, June 29, 2022 for the entire building, with all staff in compliance. Residents were escorted to areas q shift as required. without incident. Documentation was set up by a Plant designee, to ensure monthly drills would continue quarterly on each shift throughout the next year. The Interim Director of Plant Operations would confirm the scheduling and compliance of these drills for the next 12 months.