VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Landing Alexandria
2620 Main Line Blvd
Alexandria, VA 22301
(571) 577-6011

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: May 1, 2023 and May 18, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Unannounced complaint inspections were conducted on 5/1/23 and 5/18/23 in response to a complaint received by the licensing office on 4/24/23 regarding: Resident Care and Related Services. Interviews were conducted, resident records and facility documents were observed. The violation was discussed and an exit meeting was held. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint, 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. 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 (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on record review and documentation, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: Bathing - at least twice a week, but more often if needed; and Dressing. Evidence: Resident #1's care documentation was observed during the inspection. Resident #1's individualized service plan (ISP) states that an outside agency will assist with Resident #1's bathing. Resident #1's April care documentation indicates that Resident #1 was only bathed once during the period of 4/22/23 and 4/29/23, as a shower was documented as not being completed on 4/26/23 and 4/28/23. Resident #1?s April care documentation indicates that she has compression stockings applied every morning, and that the stockings are removed at bedtime. The care documentation indicates that there were four mornings when Resident #1?s compression stockings were not applied. No information was provided, during the inspection, to document why Resident #1?s compression stockings were not applied on those dates.
Plan of Correction:	1. In response to the specific situation/resident cited. 2. Resident #1 experienced no negative outcome R/T shower not completed/documented. 3. CNA/Direct Care Staff/Licensed Nurse will receive in-service/education on the importance of documenting care provided/refused on ADL record and nurses progress notes. 4. Resident Care Director will conduct random audits of ADL documentation weekly for two months and provide corrective action/education as indicated.