VIRGINIA DEPARTMENT OF SOCIAL SERVICES

West Falls Center at Falcons Landing
46661 Algonkian Parkway
Potomac falls, VA 20165
(703) 404-5300

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Oct. 20, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:55 am on 10/20/2022 and exited at 3:00pm on 10/20/2022. 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 (2 were discharged) Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating lunch and engaging in activities. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 475-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-560-E
Description:	Based upon observations, the facility failed to ensure that all resident records shall be kept in a locked area. Evidence: On 10/20/2022 at approximately 10:15 am, LI (licensing administrator) observed a resident record sitting on the railing next to the entrance of the fitness room on the second floor. At approximately 11:30 am LI observed the same record sitting on the railing next to the entrance to the fitness room on the second floor, but the medication cart was arranged in front of the record.
Plan of Correction:	No residents were harmed as result of the alleged deficient practice. The resident?s file was immediately moved to a locked area. On the spot staff education completed on secure medical records. All residents have the potential to be affected by this alleged deficient practice. Walking rounds completed on 10/20/2022. No other deficient practice noted. All nursing staff will be re-educated on ensuring that all resident records are kept in a locked area. The AL Administrator or designee will conduct walking rounds 3x weekly to ensure that records are being stored appropriately. 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 #:	22VAC40-73-970-A
Description:	Based upon a review of records, the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: According to the fire drill reports, fire drills were conducted on 6/5/2022 for the 7am to 7pm shift and on 6/21/2022 for the 7pm to 7am shift.
Plan of Correction:	No residents were harmed as result of this alleged deficient practice. All residents have the potential to be affected by this alleged deficient practice. 100% audit of facility fire drill reports was completed. No other deficient practice noted. The Maintenance and Security Departments were re-educated on the requirement for fire drills to be conducted during separate months in a quarter on 10/20/2022. The Administrator will conduct quarterly audits of fire drills for compliance. Any discrepancies will be recorded quarterly x 3 and discussed with the Quality Assurance Committee.