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 14, 2023

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

Comments:

An unannounced renewal inspection was initiated on 6/14/23 and completed on 6/16/23 . At the time of entrance, 92 residents were in care. Meals, medication administration, an activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of 10 resident records and five staff records. Exit meeting held. 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. 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 #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The records of Staff #1, Staff #2, and Staff #4 did not contain the results of a tuberculosis risk assessment completed within the past year.
Plan of Correction:	Immediate Action: On 6/21-23/23 Human Resource Director Audited all employee records to verify Tuberculosis Annual compliance of all team members. Systems added to process to prevent occurrences in the future: 6/23-27/23 Human Resource Director or designee, will develop and implement as system and data base that ensures annual requirements are met. The Human Resource Director will provide monthly audits to ensure compliance with annual Tuberculosis Risk Assessments and provide reports to the Executive Director and staff Supervisors. Responsibility: 6/27/23 and ongoing, The Human Resource Director will be responsible for implementing this system and providing daily/monthly oversight by auditing team member compliance in database. The Executive Director will provide additional oversight monthly, verifying that the system established is properly implemented and effective over the next 3 months or as needed.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement the medication management plan: methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Medication administration records (MARs) were reviewed during the inspection. Resident #2's June MAR stated that her Losartan was not administered on 6/2/23 (9 AM and 9 PM administrations), as the facility was waiting to receive the medication from the pharmacy. Resident #7's June MAR stated that her Pantoprazole was not administered on 6/3/23, as the medication was documented as being "unavailable." Resident #8's June MAR stated that his Famotidine was not administered on 6/11/23 or 6/12/23, as the medication was documented as being "unavailable."
Plan of Correction:	Immediate Action: On 6/26/23 Meeting Pharmacy regarding delay in medication fills and delivery. Audited resident Medications to verify adequate supply available for all prescribed. Systems added to process to prevent occurrences in the future: 6/27/23 Daily the Medication Aid will verify and initial that medication quantity will be evaluated, any supply with 7-days or less supply will be ordered. The Health Care Manager (Nurse) will have a tracking system to verify and confirm delivery. Pharmacy has re-established a relationship with the backup local pharmacy. Responsibility: 6/27/23 and ongoing, The Health Care Manager will be responsible for implementing this system and providing daily oversight by auditing MAR's, PCC missed medication reports, and pharmacy delivery reports. This will identify medication availability concerns early before a dose is missed. The Assisted Living Director will provide additional oversight on a weekly basis verifying that the system and procedures are successfully implemented and effective over the next 3 months or as needed.