VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Rembrandt Assisted Living, LLC
6669 Gouthier Rd
Falls church, VA 22042

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: June 5, 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 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: 06/05/2024, 9:30am-1:00pm 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch. This Licensing Inspector also observed medications being administered to residents. Additional Comments/Discussion: An exit meeting will be 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-C
Description:	Based on resident record review and staff interview, the facility failed to develop an Individualized Service Plan (ISP) that identified needs based upon the UAI. Evidence: 1. Resident 1?s ISP, developed on 8/25/2023, does not identify Mechanical Help needed for Dressing, Toileting and Eating which was assessed and as needed on the Uniform Assessment Instrument (UAI) that was completed on 8/25/2023. 2. Resident 2?s ISP, developed on 5/23/2024, indicates that the resident needs Mechanical Assist and Supervision, but the UAI, assessment completed on 5/23/2024, indicates the residents needs Supervision Only. The ISP indicates the resident is Bladder Incontinent, but the UAI indicates the resident is Continent. The ISP indicates the resident needs Supervision with ambulation, but the UAI indicates the resident needs No Help with ambulation. 3. Resident 3?s UAI assessment dated 5/3/2024, indicates the resident needs Mechanical Help and Human Help with Dressing, but the ISP, developed on 5/4/2024, only lists the need for Human Help. The UAI indicates the resident needs Mechanical Help and Supervision, but the ISP indicates the resident needs Mod Assistance. The UAI indicates the resident needs Mechanical Help and Supervision, but ISP indicates the resident `is not always able to self-propel when positioned in the wheelchair.?
Plan of Correction:	Correction: ii Standard 22VAC40-73-450 iii UAI of all residents have been checked and updated to reflect the most current resident's needs. Accordingly the ISPs have been adjusted as well. As of 07/01/2024 all UAI and ISP have been updated. Future changes in resident's needs will be reflected in their UAI as well as in their ISP.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review and staff interview, the facility failed to ensure the Medication Administration Record (MAR) listed the diagnosis, condition, or specific indication for administering the drug or supplement. Evidence: 1. Resident 1?s MAR did not list the diagnosis for the following prescribed medications: Duloxetine Hcl Dr 20 Mg or Morphine concentrate 100mg/5ml (20mg/ml) oral solution PO 5mg (0.25ml) Q8H ATC. 2. Resident 2?s MAR did not list the diagnosis for the following prescribed medications: Donopezil HCL 10mg Tablet, Memantine HCL 10mg Tablet, or Alendronate Sodium 70 mg Tab. 3. Resident 4?s MAR did not list the diagnosis for the following prescribed medications: Levothyroxine 75mcg tablet, Atorvastatin 20 Mg tablet, Amlodipine Besylate 5mg tablet, Fluoxetine 20mg capsule, Rivastigmine 4.6MG patch, Famotidine 20mg tablet, Omeprazole DR 20Mg capsule, Myrbetriq Er Mg tablet, Trazadone Hcl 50mg tablet, Nystop 100000 unit/gm powder, Fluticasone-Salmeterol inhaler, Flucticasone Proplonate 50 mcg/Actuation spray susp, or Azelastine Hcl 0.05% eye drops. 4. Resident 5?s MAR did not list the diagnosis for the following prescribed medications: Amlodipine 5mg tablet, Losartan 100mg tablet, Senna Plus 8.6-59mg tablet, Pantoprazole 40mg tablet, Sodium Chloride 1 gm tablet, Mesalamine Dr 1.2 GM tablet, or Sucralfate 1 Gm tablet.
Plan of Correction:	Correction: ii Standard 22VAC40-73-680 iii Communication with supplying Pharmacist took place on 6/24/2024. Diagnosis and/or reason for taking the medication was added to any medication listed on our resident's MARs that was missing this information.