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. 15, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2- (16) PROTECTION OF ADULTS AND REPORTING 63.2- (17) LICENSURE AND REGISTRATION PROCEDURES 63.2- (18) FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Technical Assistance:

n/a

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/15/2024 9:00am ? 12:15 pm. 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: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: N/A building vacant under renovation. Number of interviews conducted with staff: 2 Observations by licensing inspector: Building vacant and under renovation. Renovation did not include structural changes, it consisted primarily of updating floors, paint, and fixtures. Additional Comments/Discussion: Building has been vacant since January 8, 2024, and undergoing renovations since March 2024. Due to the building renovation, no residents were on-site, and the majority of documentation was in storage. A discussion was conducted with Staff 2 and Staff 3 regarding assisted living standards and ensuring compliance. Provider is to notify agency when renovations are complete and to request a modification of licensure. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-430-B
Description:	Based on record review and staff interview the facility failed to provide documentation of written notification to the resident, resident?s legal representative and designated contact person, of planned discharge and that the resident will be moved within 30 days. Evidence: 1. During Resident 1 and Resident 2chart review documentation of discharge to another assisted living facility was not found in the resident chart. 2. The LI requested documentation of written notification of discharge to the resident, legal representative, and contact person if applicable from Staff 2 and Staff 3. 3. Staff 2 stated on 8/15/2024 that documentation was provided to residents and families. However, documentation could not be located or provided to the LI during the inspection. Staff 2 acknowledged that the documentation could not be provided.
Plan of Correction:	Administrator will ensure that all discharged resident files contain a discharge statement and notification form. Administrator will audit all discharged resident files monthly to ensure compliance. Administrator will ensure all files are corrected by 11/14/24