VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vinson Hall
6251 Old Dominion Dr.
Mc lean, VA 22101
(703) 536-4344

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: March 29, 2023

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 Background Checks for Assisted Living Facilities The Sworn Statement or Affirmation

Comments:

Date of Inspection: March 29 & 30, 2023 Type of Inspection: Monitoring inspection Census 20 Number of records reviewed - 8 records, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The LI observed residents involved in activity programs and observed medication and treatment administration. The LI also reviewed record of fire drills, Healthcare Oversight, Dietary Review, Medication Review, Resident Council Minutes, Emergency Preparedness Review and Emergency Practice Drills. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@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. 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). The completed corrective action needs to be in the licensing office by April 19, 2023

Violations:

Standard #:	22VAC40-73-440-H
Description:	Based on resident record review and staff interview, it was determined that the facility failed to update the Uniform Assessment Instrument (UAI) when the resident's condition changed. Evidence: Res A, B and D had changes updated on their Individualized Service Plan (ISP), but not on their UAI.
Plan of Correction:	Clinical Director will ensure nursing staff responsible for UAI assessment and ISP documentation will complete refresher course in UAI and ISP Training within the next 90 Days. Clinical Director will ensure UAI and ISPs found to be inconsistent from review will be corrected/updated to reflect current care and services being provided immediately. Clinical Director will ensure 10% sample of resident UAI/ISP at the end of each month will be audited for 100% compliance