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 20, 2024

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness Additional Requirements for Facilities that Care for Adults with Cognitive Impairments Background Checks for Assisted Living Facilities Sworn Statement

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: 05/20/2024 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: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch. Licensing Inspector also observed medications being administered to residents. 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 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and staff interview, the facility failed to have the Individualized Service Plan (ISP) signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative annually. Evidence: 1. Resident 2, admitted on 2/28/2021, had an ISP last signed by the facility staff on 2/24/2022 and 3/22/2022 and by the resident and resident?s legal representative on 3/23/2022 on the date of inspection on 5/20/2024. 2. Resident 5, admitted on 2/24/2023, had an ISP last signed by the facility staff on 2/27/2023 and by the resident on 2/27/2023 on the date of inspection on 5/20/2024.
Plan of Correction:	Immediately updated and obtained signatures for the ISPs of Resident 2 and Resident 5. Implement a reminder system to alert staff 30 days before the annual ISP review and signature due date. Assign a staff member to monitor and ensure ISPs are signed and dated annually. Person Responsible: Resident Services Director
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to review and update the ISP at least annually. Evidence: 1. Resident 2, admitted on 2/28/2021, had an ISP that was last reviewed and updated on 2/24/2022 on the date of inspection on 5/20/2024. 2. Resident 5, admitted on 2/24/2023, had an ISP that was last reviewed and updated on 2/25/2023 on the date of inspection on 5/20/2024.
Plan of Correction:	Conducted a comprehensive review and update of ISPs for Resident 2 and Resident 5. Establish a schedule for annual ISP reviews and updates. Utilize a tracking system to ensure timely ISP reviews. Person Responsible: Resident Services Director
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review and facility policy review, the facility failed to follow the facility?s policy on Resident Self-Management and Storage of Medications regarding re-evaluating the resident?s ability to safely store and self-administer medications during each Individualized Service Plan review. Evidence: 1. Resident 2?s Assessment for Medication Self-Management was last completed on 3/25/2023 at the time of inspection on 5/20/2024. 2. Resident 5?s Assessment for Medication Self-Management was last completed on 3/25/2023 at the time of inspection on 5/20/2024.
Plan of Correction:	Conducted updated assessments for Medication Self Management for Residents 2 and 5. Integrate the Medication Self-Management assessment into the annual ISP review process. Implement a checklist to ensure all components of the ISP, including medication self-management, are reviewed. Person Responsible: Resident Service Director
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that the resident?s Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: 1. Resident 1?s MAR for May 2024 did not list the diagnosis, condition or specific indication for the following prescribed drugs: Glycopyrrolate 1mg tablet or Tussin DM 50-5ML liquid. 2. Resident 2?s MAR for May 2024 did not list the diagnosis, condition or specific indication for the following prescribed drugs: Prednisone Acetate 1% drops susp. 3. Resident 3?s MAR for May 2024 did not list the diagnosis, condition or specific indication for the following prescribed drugs: Atorvastatin Calcium F/C 40mg tablet, Citalopram HBR F/C 20mg tablet, Diclofenac Sodium 1% gel, Gapapentin 300mg capsule, Hydrochlorothiazide 25mg tablet, Lidocaine Pain Relief 4% ADH patch, Reguloid 0.36G capsule, Restasis SUV 0.05% droperette, Valacyclovir F/C 500mg tablet, Valsartan 80mg tablet, Vitamin B-12 1000mcg tablet. 4. Resident 4?s MAR for May 2024 did not list the diagnosis, condition or specific indication for the following prescribed drugs: Multivitamins with minerals 7.5MG-400 tablet, Preservision Areds 2 + Multi solftgel capsule, Melatonin 3mg tablet.
Plan of Correction:	Updated the MARs for Residents 1, 2, 3, and 4 to include the diagnosis, condition, or specific indications for each medication. Implement a policy requiring that all new MAR entries include the diagnosis, condition, or specific indication. Conduct regular audits of MARs to ensure compliance. Person Responsible: Registered Medication Aide and Resident Service Director