VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chantilly Heights
3925 Downs Drive
Chantilly, VA 20151
(703) 810-3992

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: July 25, 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 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 63.2- (1) GENERAL PROVISIONS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 7/25/2024, 9:00am-6:05pm. 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: (38) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and activities Additional Comments/Discussion: n/a 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-B
Description:	Based on direct observation and review of resident files, the facility failed to develop a comprehensive ISP (Individualized service plan) to meet the resident?s service needs. Evidence: 1. Resident 1?s ISP does not indicate the need for a ?STOP SIGN? velcro banner across their door. 2. Resident 2?s ISP does not indicate the need for a ?STOP SIGN? velcro banner across their door. 3.Staff #1 stated that the ?STOP SIGN? usage is to keep wandering resident(s) from entering the rooms of Resident #1and #2. 4. Photos taken as evidence.
Plan of Correction:	Stop Sign Banner added to ISP 7/26/24 Resident will be supported to use STOP sign banner at doorway entry as requested by POA. CH staff to put banner up via velcro when resident is out of the room at daytime to decrease other residents wandering into resident apartment. date initiated 7/26/24. CH staff to round on resident apartment Q2H when STOP sign banner is up. Initiated 7/26/24 copy of ISP attached and was sent previously by DON
Standard #:	22VAC40-73-640-D
Description:	Based on direct observation, staff interviews and audit of the medication cart, the facility failed to ensure that in addition to the facility?s written medication management plan, the facility shall have readily accessible at least one pharmacy reference book, drug guide, or medication handbook no more than two years? old. Evidence: 1. The facility did not have a drug reference book on the medication carts or in the medication/Nurse?s station. 2. Staff 2 was asked to locate the drug reference book but was not able to do so.
Plan of Correction:	2 Nursing 2025-2026 Drug Handbooks ordered. Publisher Lippincott Williams & Wilkins (sold by Amazon) ordered 7/29/24 receipt attached.
Standard #:	22VAC40-73-870-A
Description:	Based on direct observation, the facility failed to make certain the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1.In the kitchen walkway area, there were floor tiles that were lifted up and damaged. 2.The floor tiles were lifted up in a manner to be a potential tripping hazard. 3.Photos taken as evidence.
Plan of Correction:	Removal of flooring 813 sf @ $2 per ft =$1626 -Preparing the floor from glue and any other materials under $750 -Cleaning the concrete and sealing the floor using clear concrete sealer $813 Option-For installing new LVP clue down minus the floor sealer the cost for new flooring in a natural finish $4,065.00.