VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Johnson Center at Falcons Landing
20535 Earhart Place
Potomac falls, VA 20165
(703) 404-5201

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: March 16, 2022 and March 21, 2022

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Comments:

An unannounced monitoring studying began on 3/16/2022 and concluded on 3/21/2022. At the time of entrance 19 residents were in care. The sample size consisted of six residents records, one discharged resident record, three staff records, and two volunteer records. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 9/2/2020 were reviewed. LI walked the physical plant. Residents were observed eating breakfast and lunch and engaging in activities including exercise and watching TV. Medication administration was observed. Violation notice issued, risk ratings reviewed and exit interview held. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1090-B
Description:	Based upon a review of records, the facility failed to ensure that the assessment required in subsection A of this section shall be maintained in the resident's record. Evidence: The records for Resident #5 and Resident #6 did not contain documentation that prior to placement to a safe, secure environment, the residents were assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry).
Plan of Correction:	No residents were harmed as result of the alleged deficient practice. An Assessment of Cognitive Impairment was completed for Resident #5. An Assessment of Cognitive Impairment was completed for Resident #6. All residents have the potential to be affected by this alleged deficient practice. 100% audit completed of Memory Care residents to ensure the completion of Cognitive Impairment Assessment. Issues addressed. AL Coordinator will be re-educated on the regulation for cognitive impairment assessments. Attending Physician's will be re-educated on the regulation for cognitive impairment assessments. Administrator or designee will audit new admissions to the memory care unit for compliance as needed and report the findings to the Quality Assurance Committee. A quarterly summary report will be provided to the Quality Assurance Committee.
Standard #:	22VAC40-73-1100-B
Description:	Based upon a review of resident records, the facility failed to ensure that the obtained written approval for placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia, in a safe, secure environment shall be retained in the resident's record. Evidence: The record for Resident #5 did not contain the written approval for placement in a safe, secure environment from one of the following persons in order of priority: the resident, if capable of making an informed decision; a guardian or other legal representative for the resident if one has been appointed; a relative who is willing to take on responsibility to act as the resident's representative; or an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia.
Plan of Correction:	No residents were harmed as a result of the alleged deficient practice. An approval for placement was obtained by the Physician for Resident #5. All residents have the potential to be affected by this alleged deficient practice. 100% audit completed of Memory Care residents to ensure the approval for placement had been obtained. Issues addressed. AL Coordinator will be re-educated on the regulation for written approval for placement in a safe, secure environment. Attending Physician's will be re-educated on the regulations for written approval for placement in a safe, secure environment. Administer or designee will audit new admissions to the memory care unit for compliance as needed and report the findings to the Quality Assurance Committee. A quarterly summary report will be provided to the Quality Assurance Committee.
Standard #:	22VAC40-73-1110-B
Description:	Based upon a review of records, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: According to the record for Resident #6, the last annual review of appropriateness of continued residence in the special care unit was completed on 2/11/2021.
Plan of Correction:	No residents were harmed as a result of the alleged deficient practice. An annual review of appropriateness was completed for Resident #6. All residents have the potential to be affected by this alleged deficient practice. 100% audit completed of Memory Care residents to ensure the timely completion of "appropriateness for placement." Issues addressed. AL Coordinator will be re-educated on the regulation for timely completion of "appropriateness for placement." Attending Physician's will be re-educated on the regulation for timely completion of "appropriateness for placement." Administrator or designee will audit the memory care unit for compliance as needed and report the findings to the Quality Assurance Committee. A quarterly summary report will be provided to the Quality Assurance committee.
Standard #:	22VAC40-73-320-A
Description:	Based upon a review of records, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician and that the report of such examination shall be on file at the assisted living facility and shall contain the following: a statement that specifies whether the individual is or is not capable of self-administering medication is included on the physical examination report. Evidence: The history and physical form for Resident #1 completed on 6/2/2021 and the history and physical form Resident #5 completed 11/2/2020, did not contain a statement that specifies whether the residents are capable of self-administering medication.
Plan of Correction:	No residents were harmed as result of the alleged deficient practice. A self-administration medication assessment was completed for Resident #1. A new Physical Examination form was completed. A self-administration medication assessment was completed for Resident #5. A new Physical Examination form was completed. All residents have the potential to be affected by this alleged deficient practice. 100% audit completed of current AL/Memory Care residents completed for compliance with physical examination form/medication administration assessment. All nursing staff will be re-educated on the accurate physical examination form. All attending physician's will be re-educated on the accurate physical examination form. The AL Coordinator or designee will review resident charts monthly for annual reviews. The AL Coordinator or designee will review all new admissions to ensure that the accurate physical examination form was used. Any discrepancies will be recorded monthly x3 and discussed with the Quality Assurance Committee. A quarterly summary report will be provided to the Quality Assurance committee.
Standard #:	22VAC40-73-450-C
Description:	Based upon a review of records, the facility failed to ensure that the comprehensive individualized service plan shall be completed within 30 days after admission and shall include the following: description of identified needs and date identified based upon the (i) UAI and a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them; Evidence: 1. The Uniform Assessment Instrument (UAI) dated 11/24/2021 identified that Resident #2 requires human help only with supervision in the areas of transferring and eating. The UAI documents that Resident #2 is disoriented to the spheres of place and time "some of the time." The Individualized Service Plan (ISP) dated 12/17/2021 (same date Resident #2 was admitted to the facility) documents that for transferring, Resident #2 "needs mechanical assistance and staff supervision with transfer. Resident will use his walker arm of chair or grab bars to safely transfer." The ISP does not provide a description of how Resident #2 will be assisted with eating and does not provide a description of how Resident #2 will be assisted with disorientation to time and place. 2. The UAI dated 12/7/2021 documents that Resident #4,who was admitted to the facility on 12/9/2021, requires mechanical help and human help/supervision with the activity of bathing. The ISP dated 12/7/2021 states that for bathing, Resident #2 "requires mechanical and limited physical assistance with his bathing needs. Care staff will assist him to get in and out of the shower safely."
Plan of Correction:	No residents were harmed as result of the alleged deficient practice. The ISP for Resident #2 was updated on 3/21/2022 to reflect the description of how the resident will be assisted with eating and how the resident will be assisted with disorientation to time and place. The ISP for Resident #4 was updated on 3/21/2022 to reflect the description of how the resident will be assisted with bathing. All residents have the potential to be affected by this alleged deficient practice. 100% audit of all current resident ISP's will be completed to ensure the accurate description of assistance needed by staff. The AL Coordinator will be re-educated on the importance of describing the resident's identified needs, date identified, and what services will be provided to address the identified needs. The Administrator will conduct monthly audits or resident charts to ensure compliance with individualized service plans. Any discrepancies will be recorded monthly x3 and discussed with the Quality Assurance Committee. A quarterly summary report will be provided to Quality Assurance Committee.