VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Kensington Reston
11501 Sunrise Valley Drive
Reston, VA 20191
(571) 494-8100

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Aug. 5, 2024 and Aug. 6, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES2VAC40-73 GENERAL PROVISIONS 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 ADULT 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 22VAC40-80 THE LICENSING PROCESS

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: 8/5/24 (8:14 AM - 6:15 PM), 8/6/24 (8:45 AM - 6:40 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: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds at the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents 4 Observations by licensing inspector: Building and grounds, meals, medication administration, activities, background checks of new staff (hired since the last inspection) Additional Comments/Discussion: An exit meeting was 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 to the facility to compliance and maintain future compliance with 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 (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on a review of six staff records, it was determined that the facility did not ensure that all direct care staff attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals orcertified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. The record for Staff #2, hired 8/24/15 as a LPN. Staff #6 reported that Staff #2 was originally hired at a sister facility, and that Staff #2 transferred to this facility on 10/25/22. 2. Facility training documents indicate that Staff #2 attended 5.5 hours of training within the annual review period of 10/25/22 through 10/25/23.
Plan of Correction:	1. Staff #2 has completed all required training for the current year. 2. Education to be provided to Staff #2 on expectations related to the completion of annual training. 3. A 100% audit of annual training for team members will be completed to ensure completion of training modules for the current year. Corrective action will be initiated for any variances and findings will be reported to the Executive Director. 4. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-220-B
Description:	Based on a review of documentation, it was determined that the facility did not ensure that all of the required information is present for private duty personnel, who are not employees of a licensed home care organization. Evidence: 1. Private duty aide documentation was reviewed during the inspection. No criminal history record report or qualifications were included in the files for the private duty aides for Resident #12 or Resident #13.
Plan of Correction:	1. Files will be reviewed for two private duty personnel who are not employees of licensed home care organizations to ensure required information is on file. Corrective action to ensure required information is present and on-file will be completed by 09/30/24. 2. A 100% audit of files for private duty personnel who are not employees of a licensed home care organization will be completed to ensure the required information is present and on-file. Corrective action will be initiated for any variances, and findings will be reported to the Executive Director. 3. Subsequently executed private duty personnel agreements with those not employed by a licensed home care organization will be double-checked by Executive Director or designee to ensure the required information is present and on-file. 4. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-310-M
Description:	Based on a review ten resident records, it was determined that the facility did not ensure that the hospice provider agreement includes all of the required information. Evidence: 1. The record for Resident #9 contained a hospice agreement between the facility and Company A that was not signed by a facility representative, or a representative of Company A.
Plan of Correction:	1. Hospice contract will be corrected and/or amended to include the required information and will be properly executed and signed by 10/31/2024. 2. Additional/other hospice contracts will be reviewed to ensure all the required information is included. 3. Corrective action will be initiated for any variance, and findings will be reported to the Executive Director. 4. Subsequently executed hospice contracts implemented will be double-checked by company partners to ensure they include all required elements. 5. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-430-H-1
Description:	Based on a review of ten resident records and interview, it was determined that the facility did not ensure that a discharge statement is provided to the resident, at the time of discharge. Evidence: 1. Resident #11's discharge documentation was reviewed during the inspection. Resident notes indicate that Resident #11 never returned to the facility after a hospitalization on 3/16/24. 2. Resident #11's discharge statement indicates the resident?s contact person was notified about the discharge verbally on 3/16/24. No information was included on the discharge form, to indicate when and to whom the discharge statement was provided. 3. Staff #6 confirmed that discharge notification was only provided verbally.
Plan of Correction:	1. No current residents are being actively discharged at this time. 2. Education to be provided on the protocol for ensuring discharge statements are provided, in writing, to resident responsible parties, within the required timeframe 3. Discharge statements from the past three months to be audited to ensure protocol was followed for residents who may have been discharged from the community due to a circumstance or condition necessitating a discharge. Corrective action will be initiated for any variance, and findings will be reported to the Executive Director. 4. Future discharge statements relating to emergency discharges will be double-checked by company partners or designee to ensure they are provided to residents? responsible parties within the required timeframe. 5. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-450-C
Description:	Based on a review of ten resident records, it was determined that the facility did not ensure that the comprehensive individualized service plan (ISP) includes identified needs and dates based upon the uniform assessment instrument (UAI). Evidence: 1. Resident #1's UAI, dated 2/4/24, states hat she needs mechanical assistance and supervision for bathing. Resident #1's ISP, dated 3/2/24, states that she needs physical assistance for bathing. 2. Resident #6's UAI, dated 6/6/24, states that he needs mechanical and physical assistance for toileting. Resident #6's ISP, dated 6/6/24, states that the resident requires one person assistance in managing bowel and/or bladder care. 3. Resident #7's UAI, dated 4/16/24, states that the resident needs no assistance for bathing, dressing, toileting, or transferring. Resident #7's ISP, dated 4/16/24, states that the resident needs physical assistance for bathing, dressing, toileting, and transferring.
Plan of Correction:	1. A review of resident #1, #6, and #7?s Individualized Service Plans took place. Corrections have been made to ensure identified needs are based upon the Uniform Assessment Instrument. 2. A 10% audit of residents? Individualized Service Plans and UAIs will be conducted by the Executive Director or designee, monthly for three months, to ensure identified needs are based upon the Uniform Assessment Instrument. Corrective action will be initiated for any variances and findings will be reported to the Executive Director. 3. Executive Director or designee to educate designated team members on practices related to ensuring the identified needs on the Individualized Service Plan are based upon the Uniform Assessment Instrument. 4. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation and a resident record review, it was determined by that the facility did not ensure that the medication storage area remains locked. Evidence: 1. The facility's second-floor treatment cart was observed to be unlocked and unattended, during a facility tour at approximately 8:58 AM on 8/5/24. 2. The second-floor treatment cart contained Resident #10's Ketoconazole cream (ordered 7/11/24). 3. Staff #6 conducted the tour, and locked the cart after being informed that the cart was unlocked.
Plan of Correction:	1. Medication storage cart (treatment cart) was locked during inspection on 8.5.24. 2. Additional treatment carts inspected on 8.5.24 were deemed to be locked. 3. Education to be provided to nursing team members on protocols for locking treatment carts. 4. A 100% audit of treatment carts to ensure proper locking will be completed by a licensed nurse or designee, daily for 4 weeks. Corrective action will be initiated for any variance, and findings will be reported to the Executive Director. 5. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-680-E
Description:	Based on a review of ten resident records, it was determined that the facility did not ensure that medical procedures ordered by a physician shall be provided according to his instructions and documented. Evidence: 1. Resident #4's record contained an order for Metoprolol Succinate 50mg to be administered daily. The order states "hold for systolic blood pressure <110 or Heart Rate <55." 2. Resident #4's July and August MARs only contained documentation of the resident's vital signs on the first day of the month. No records were provided, during the inspection, to verify that Resident #4's blood pressure was taken before each administration of her Metoprolol Succinate.
Plan of Correction:	1. The data entry field for the vital sign data to be noted in the electronic medication administration record was corrected for Resident #4 on 8/5/24. 2. A 100% audit of residents with orders for blood pressure medication with parameters was completed to ensure that the data entry field for the vital sign data was visible in the electronic medication record. Corrective actions have been initiated for any variances, and findings were reported to the Executive Director. 3. Education will be provided to the nursing team regarding required steps for medication order approvals for residents with medications with parameters. 4. A 100% audit of residents with orders for blood pressure medication with parameters will be completed monthly for 3 months to ensure that the data entry field for the vital sign data is visible in the electronic medication record. 5. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-830-E
Description:	Based on a review of documentation and interview, it was determined that the facility did not ensure that a written response is provided to the resident council regarding recommendations about problems/concerns. Evidence: 1. The facility's resident council binder was observed during the inspection. Notes from the 6/25/24 resident council meeting indicated that resident recommendations were provided regarding staff entry into resident rooms, and for regular visual sweeps of the dining room. 2. The most recent resident council meeting occurred on 7/30/24. No written response to the resident recommendations from the previous meeting on 6/25/24 had been provided to the council, before the 7/30/24 meeting. 3. Staff #6 confirmed that a written response had not been provided to the council regarding the resident recommendations.
Plan of Correction:	1. Written response to problems/concerns raised during the last resident council meeting (July) will be provided to the council prior to the next Resident Council meeting (Aug). 2. Education to be provided to appropriate team members on the protocol for resident council communication by 08/31/24. 3. Process changes include completion of Resident Council Minutes within one week of the meeting; Minutes to be reviewed by the Executive Director to ensure resolutions are documented; Assisted Living Manager or designee to ensure written responses are provided to residents prior to the following months? meeting. 4. A monthly audit will be conducted by Executive Director or designee to ensure resolutions are provided to residents in advance of each meeting. Corrective action will be initiated for any variance and findings will be reported to the Executive Director. 5. Person Responsible: Executive Director or designee