VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arbor Terrace Prince William Commons
14080 Central Loop
Woodbridge, VA 22193
(703) 721-8801

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: June 28, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

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: 06/28/024: 08:45 AM to 5:30 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: 126. The licensing inspector completed a tour of the physical plant that included a resident room and the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-B
Description:	Based on staff interview, the facility failed to maintain a written plan that specifies the number and type of direct care staff required to meet day to day, routine direct care needs and any identified special needs for the residents in care. Evidence: 1. A copy of the written staffing plan was requested to Staff 1. 2. Staff 1 provided a copy of a blank disclosure statement that contained the general number, position types, and qualifications of staff as well as a current schedule in lieu of a staffing plan. 3. Staff 1 confirmed they do not have a written staffing plan that specifies the number and type of direct care staff required to meet day to day routine direct care needs and any identified special needs for the residents in care.
Plan of Correction:	Written Staffing Plan created and implemented on 8/12/24. Please review the attached copy of current plan in place. Staffing plan will be updated by ED/BOD on a quarterly basis to reflect the changing acuity of residents.
Standard #:	22VAC40-73-350-A
Description:	Based on staff interview, the facility failed to register with the Department of State Police to receive notice of the registration or re-registration of any sex offender within the same or a contiguous zip code area in which the facility is located. Evidence: 1. A copy of the facility?s registration for notifications from the Department of State Police for notice of the registration or re-registration of any sex offender within the same or a contiguous zip code was requested to Staff 1 and 2. 2. The facility provided a copy dated for 2023 sent to a staff member that was no longer employed by the facility. A more recent copy was requested. 3. Staff 1 confirmed that they are not currently registered, and all email notifications are likely going to the staff member that is no longer employed by the facility.
Plan of Correction:	Registration completed July 2024. Community is currently receiving notifications of sex offenders within a 5-mile radius of the community. Reports/ notifications are saved and stored in ED office for resident/ family viewing upon request.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender and document in the resident?s record that this was ascertained with the date the information was obtained. Evidence: 1. A registered sex offender check for Residents 1, 6, and 9 was not documented in the resident records. 2. Staff 1 stated the facility did not have copies of the sex offender checks completed prior to admission.
Plan of Correction:	Resident 1,6, and 9 sex offender checks were completed. Staff in-service/ training completed on 7/1/24. Monthly audit will be conducted by ED/BOD to ensure all new admission files have a completed sex offender report completed prior to admission date
Standard #:	22VAC40-73-350-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that each resident or his legal representative is fully informed, prior to admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information. Evidence: 1. There was no documentation of the facility notification that residents should exercise whatever due diligence he deems necessary with respect to information on registered sex offenders in the files of Resident 1, 2, 3, 4, 5, 6, 7 or 8. 2. Staff 1 confirmed they were not being completed at time of admission or annually.
Plan of Correction:	Resident and/ or legal representative will be informed prior to admission and annually regarding sex offender reports. Reports are saved and stored in ED office for viewing upon request.
Standard #:	22VAC40-73-410-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that an orientation was provided for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Evidence: 1. There was no documentation of the facility orientation that includes emergency response procedures, mealtimes, and the use of the call bell system in the files of Resident 1, 2, 3, 4, 5, 6, 7 or 8. 2. Staff 1 confirmed it was not being completed at time of admission.
Plan of Correction:	Orientation and signature form have been created and will be reviewed & signed by resident and/or legal representative. Ongoing compliance will be monitored by ED/BOD by completing monthly audits of new admission files.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the ISP contains all identified needs. Evidence: 1. Resident 1 has a Uniform Assessment Instrument (UAI) dated 05/23/2024 documenting that Resident 1 takes medication without assistance. 2. Resident 1 has a Self-Administration of Medication Assessment completed on 06/14/2024 completed by Staff 2 documenting that the resident can self-administer medication. 3. Staff 2 confirmed the resident self-administers medication. 4. Resident 1?s initial ISP, dated 06/14/2024, documents that Resident 1 ?requires assistance with medication management.? The ISP lists that ?Licensed Staff or Registered Medication Aides will administer all meds as prescribed by healthcare provider.?
Plan of Correction:	Resident 1 ISP and UAI was updated and corrected. Ongoing compliance will be monitored by DRC, LPN, and MC Dir.
Standard #:	22VAC40-73-460-B
Description:	Based on facility record review and resident interview, the facility failed to ensure that care provision and service delivery included prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. Resident 8 and Resident 10 both indicated having to wait frequently when they ask for assistance in an interview with the LI. 2. The call bell records for Resident 4 were reviewed from 06/01/2024 to 06/28/2024. The longest response time was 56 minutes. There were 39 instances where the resident had to wait longer than 12 minutes. 3. The call bell records for Resident 5 were reviewed from 06/01/2024 to 06/28/2024. The longest response time was 62 minutes. There were 22 instances where the resident had to wait longer than 12 minutes. 4. The call bell records for Resident 2 were reviewed from 06/01/2024 to 06/28/2024. The longest response time was 99 minutes. There were 3 instances where the resident had to wait longer than 12 minutes. 5. The call bell records for Resident 8 were reviewed from 06/01/2024 to 06/28/2024. The longest response time was 64 minutes. There was 1 instance where the resident had to wait longer than 12 minutes.
Plan of Correction:	Staff training and in-service completed on 8/7-8/9 Dept. Managers will randomly pull call bells to ensure staff are responding timely. ED/DRC will review call bell reports weekly and follow up with staff accordingly. Resident/responsible party have been encouraged to report delays in call bell response time to ED/DRC
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review and staff interview, the facility failed to ensure that when oxygen therapy is provided, a valid physician or other prescriber?s order includes the source, delivery device and flow rate. Evidence: 1. Resident 3 has an oxygen order, dated 01/30/2024, that states ?Administer at 2L via NC PRN Titrate up to 5LPM for SOB.? 2. The oxygen order was reviewed with Staff 1 and 2 who confirmed it did not contain the source of oxygen.
Plan of Correction:	Resident 3 oxygen orders were clarified and updated by physician on 6/28/24. Ongoing compliance by RCD/LPN will ensure all orders for oxygen are written correctly with source of oxygen included
Standard #:	22VAC40-73-860-I
Description:	Based on direct observation, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. Evidence: 1. In the laundry room of floor two, a box of powder detergent and dryer sheets were observed in the cabinet. 2. In the laundry room of floor three, one bottle of liquid laundry detergent and one box of powder detergent were observed on the counter and in the cabinet. The powder was spilled on the cabinet. 3. Photo Evidence Taken.
Plan of Correction:	Liquid laundry detergent and powder detergent found on Assisted Living. Residents on AL will be given a friendly reminder in resident council meetings scheduled for August, Sept.and Oct. 2024 to ensure Residents remove their personal laundry supplies timely and do not leave unattended. A sign will also be posted as a reminder to residents in laundry rooms. daily monitoring will be provided by hskp/ maint. staff