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: May 15, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:45 am on 5/15/2023 and exited at 1:15 pm on 5/15/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 3/22/2023 regarding allegations in the area(s) of resident care and related services. LI inspected to ensure that previous B2 violations were corrected. Number of residents present at the facility at the beginning of the inspection: 64 Number of resident records reviewed: 8 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based upon a review of records, the facility failed to ensure that Individualized Service Plans (ISPs) shall be reviewed and updated at least once every 12 month and as needed for significant change of a resident?s condition. Evidence: 1. On 5/15/2023 LI reviewed the current ISP in the record for Resident #1 and found that the ISP was dated 2/3/2022.
Plan of Correction:	All resident Individual Service Plans (ISPs) will be audited monthly for accuracy and timely updates. New Resident Services Director (RSD) will generate monthly report from community Electronic Medical Record (EMR) on upcoming ISP due dates. New RSD will complete EMR training with contractor for program efficiency.
Standard #:	22VAC40-73-680-I
Description:	Based upon a review of records, the facility failed to ensure that Medication Administration Records (MARS) include the following: date and time given and initials of direct care staff administering medication. Evidence: 1. On 5/15/2023, LI found the following information documented in sampled 2. resident records: a. The March 2023 MAR for Resident #1 evidenced there were no initials or time administered for the medications Aspirin, Cetirizine, Hydrocodone, Sertraline, Vitamin B, and Vitamin D on 3/2/2023 at approximately 8am. b. The May 2023 MAR for Resident #5 evidenced there were no initials or time administered for the medication Clonazepam on 5/10/2023 and 5/11/2023 at approximately 3:00pm.
Plan of Correction:	Mediation Administration documentation in-service will be conducted by Resident Services Director . Daily review of Medication Administration Records (MAR) and Treatment Administration Records (TAR) for omissions and/or errors will be conducted by RSD at the beginning of shift and end of day.