VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lavendar Hills Prince William Campus
10140 Hastings Drive
Manassas, VA 20110

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Aug. 18, 2022 and Aug. 22, 2022

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 Buildings and Grounds Emergency Preparedness Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairment Mixed Population

Comments:

Date of Inspection: August 18 and 22, 2022, 8:45am-3pm Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 19 Number of records reviewed and interviews conducted- 13 records (staff and resident), 7 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The residents were observed during breakfast and lunch. Also, the residents were observed during activities. Medication administration was observed. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have documentation of a coordinated plan of care between the facility and the hospice agency on the Individualized Service Plan (ISP) as required. Evidence: Resident A had no coordinated plan of care on the ISP dated June 15, 2022.
Plan of Correction:	Resident A's ISP will have documentation reflecting the coordinated plan of care between the Hospice agency and the facility. All residents receiving hospice services will have a record audit to ensure compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, it was determined that the facility failed to document a change in condition on the Individualized Service Plan (ISP) as required. Evidence: Resident A had no documentation on the ISP dated June 15, 2022 of the mechanical soft diet ordered by the physician.
Plan of Correction:	Resident As ISP will have current documentation to show the mechanical soft diet ordered by the physician. All resident charts will be audited to ensure that any changes have been captured and documented.