VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tilden Memory Care
7800 Belvedere Drive
Alexandria, VA 22306
(571) 556-9339

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: April 24, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on a facility record review and staff interviews, the facility failed to report major incidents that threatened the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. Evidence: 1. Resident 2?s record contained documentation dated 01/10/2024 that stated an onset of an unspecified wound. 2. On 04/24/2024, Staff 2 (hire date, 01/01/2023) and Staff 4 (hire date, 01/01/2023); both stated, they were ?unaware? of the requirement to report incidents, such as wounds to the regional licensing office.
Plan of Correction:	What did you do to fix this specific violation? The administrator told the inspector that moving forward all resident wounds will be reported within 24-hours via email steps are you going to implement to ensure future compliance? The administrator told the LPN and third-party wound nurse to inform him of any new resident wounds so that he can report them to the regional licensing office What measures will be put into place to monitor compliance? Direct care staff have been instructed to alert the LPN and administrator of any new resident wounds dWhat date will this be completed by? All new resident wounds will be reported to the regional licensing office via email within 24-hours of initial observation
Standard #:	22VAC40-73-690-G
Description:	Based on resident record review and staff interview, the facility failed to ensure that action was taken in response to the recommendations noted in the medication review and that this is documented in the resident record. Evidence: 1. Resident 2 and Resident 3?s Pharmacy Reviews were completed on 09/20/2023, 03/13/2023, and 03/28/2023. 2. No documentation was present in Resident 2 or Resident 3?s record regarding action taken to recommendation in the medication review. 3. On 04/24/2024, LI interviewed Staff 4, who stated that he ?did not know? it was a requirement to respond to physician recommendations for pharmacy reviews.
Plan of Correction:	What did you do to fix this specific violation? The third-party medication audits will be sent to each residents? primary care provider for review. The facility will document that the audits were sent and if the primary care providers wish to change medication orders based upon the recommendations. What steps are you going to implement to ensure future compliance? Moving forward the facility will keep documentation showing that bi-annual medication audits were sent to residents? primary care providers and if providers wished to change medication orders based upon the recommendations. What measures will be put into place to monitor compliance? Documentation will be uploaded into the facility?s Synkwise electronic health records system with an alert set to trigger the administrator and staff one month before expiration. What date will this be completed by? This will be completed within one week of receiving the next bi-annual audit, which is expected to arrive 6/30/2024.
Standard #:	22VAC40-73-940-A
Description:	Based on facility record review and staff interview, the facility failed to ensure that at least an annual inspection by the appropriate fire official was conducted and reports of the inspections shall be retained at the facility for at least two years. Evidence: The most recent inspection completed by the fire official was completed on 11/04/2022. On 04/24/2024, LI interviewed Staff 4, who stated, ?the Fire Marshal and former LI did not advise that I needed an annual inspection completed.?
Plan of Correction:	What did you do to fix this specific violation? The administrator immediately ordered a new fire safety inspection to be performed by the Fairfax County Fire Marshall. An inspection was conducted on May 29, 2024, and zero violations were found. A new annual permit was issued (inspection sequence #3342969). What steps are you going to implement to ensure future compliance? A new fire safety inspection will be conducted every twelve months cWhat measures will be put into place to monitor compliance? The annual fire permit has been uploaded into the facility?s Synkwise electronic health records system with an alert set to trigger the administrator and staff one month before expiration. A new inspection will be ordered one month before the current permit expires. What date will this be completed by? A new annual fire safety inspection will be conducted by May 29, 2025, which is when the current permit expires.