VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pacifica Senior Living Sterling
46555 Harry Byrd Highway
Sterling, VA 20164
(703) 896-9590

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Oct. 29, 2021 and Nov. 1, 2021

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 study was conducted from 9:00 a.m. - 1:00 p.m. on 11/01/2021. At the time of entrance 51 residents were in care. The sample size consisted of four resident records, and four staff records. Staff interviewed. Resident and staff records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection were reviewed. Residents and staff were observed during lunch. Medication administration was observed with two staff. Two medication carts observed for PRN medications. Building and Grounds observed. Violation notice issued and risk ratings reviewed at exit interview with administrator on 12/07/2021. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-90-30-B
Description:	Based on record review, facility failed to ensure that a Sworn Statement (SS) or affirmation shall be completed for all applicants for employment. EVIDENCE: Staff 15 was hired on 7/22/2021 with a SS dated 9/27/2021 that was incomplete; Staff 21 was hired on 5/16/2019 with a SS that was not dated; Staff 24 was hired on 7/01/2018 with a SS dated 5/27/2021 that was incomplete; Staff 27 was hired on 5/1/2018 with a SS that was not dated; and Staff 29 was hired on 5/01/2018 with an SS that was not dated.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-30-C
Description:	Based on record review, facility failed to ensure that any person making a maerially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor. EVIDENCE: Staff 20 was hired on 9/02/2021 and Staff 20's Sworn Statement dated 9/02/2021 does not identify past criminal history that is documented on the Criminal History Record dated 9/16/2021,
Plan of Correction:	Not available online. Contact Inspector for more information.