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: Jan. 26, 2024 , Jan. 30, 2024 and Feb. 7, 2024

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: 1/26/24 (3:00 PM - 4:10 PM), 1/30/24 (3:30 - 4:40 PM), 2/7/24 (3:20 PM - 4:40 PM). 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 the VDSS Division of Licensing on 1/24/24, regarding an allegation in the area of: Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: One Number of interviews conducted with residents: Three Number of interviews conducted with staff: Six 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. 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 #:	63.2-1808-A-15
Description:	Based on documentation and interviews, the facility failed to ensure that each resident is free of physical restraint except in the following situations with appropriate safeguards: a. As necessary for the facility to respond to unmanageable behavior in an emergency situation, which threatens the immediate safety of the resident or others; b. As medically necessary, as authorized in writing by a physician, to provide physical support to a weakened resident; Evidence: On 1/19/24, several witnesses reported that Resident #1 entered the kitchen area during the evening meal to sing a song to the staff members. Resident #1 was asked to leave the kitchen area, but she refused and told the staff members not to touch her. Staff #1 reportedly wrapped her arms around Resident #1 and physically removed the resident from the kitchen area. Virginia administrative code (22VAC40-73-10) defines a physical restraint as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident?s body that the resident cannot remove easily, which restricts freedom of movement or access to his body. The Centers for Medicare and Medicaid Services defines the "manual method" as a means to hold or limit a resident?s voluntary movement by using body contact as a method of physical restraint. None of the interviews indicated that Resident #1, or any other resident, was in immediate danger by Resident #1's presence in the kitchen area. Staff #1's record was reviewed during the inspection and it indicates that she was hired on 12/19/22 as the Assistant Dining Services Director. No documentation, was included in Staff #1's record, to confirm that she met the qualifications for direct care staff to provide any type of physical assistance to residents, nor did the record contain any training for the implementation of restraints. The record for Resident #1 did not include a physician?s order for the use of physical restraints and her individualized service plan (ISP) did not include any information about her needing any assistance for standing/walking.
Plan of Correction:	Resident #1 was assessed by Nursing; no injuries were noted nor did Resident #1 complain of any pain. All community staff were in-serviced on abuse (focusing on the different categories) and the protocols for reporting. Additionally, staff were educated about different ways they could intervene in similar situations without the need to physically restrain a resident. Staff are in-serviced on abuse as part of their on-boarding, as well as annually via the community's Relias training system. Additional staff training and education will be conducted as needed.