VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Insight Memory Care Center
3953 Pender Drive
Suite 100
Fairfax, VA 22030
(703) 270-0044

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: April 2, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 PROGRAMS AND SERVICES

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/02/2025 1:30 PM to 3:35 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/31/2025 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Activities Number of participants present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 7 Number of staff records reviewed: 0 Number of interviews conducted with participants: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Activities and Meals Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-61-60-A
Complaint related:	Yes
Description:	Based on center document review, direct observation, and staff interview, the center failed to ensure compliance with the center?s own policies and procedures. Evidence: 1. In an interview with the Licensing Inspector (LI), staff 1 provided the center?s policies regarding staffing and the levels of service. 2. The Levels of Service policy, updated 3/3/2025, states the following ??The staffing ratio for our coral program is 1 staff person to every 3 participants (better than state requirements), which allows us to provide physical assistance with activities of daily living as well as rich personal interactions?? 3. On 4/2/2025, the LI observed eight (8) participants in the coral group with two (2) staff members. 4. In an interview with the LI, staff 1 confirmed that there was not enough staff to meet the 1:3 ratio detailed in the Levels of Service Policy. 5. The Staffing Ratio Maintenance policy, updated 3/3/2025, states the following ?Insight Memory Care Center will provide a minimum of one staff person on duty providing direct care and supervision for every six participants in care...? 6. On 4/2/2025, the LI observed 47 participants in programs with four (4) assigned direct care staff providing support. 7. In an interview with the LI on 4/2/2025, staff 1 confirmed they did not have enough staff providing direct care and supervision.
Plan of Correction:	Corrective Action Taken: Conducted a comprehensive internal review to identify specific protocol failures and the staff and department involved. Systemic Change: All operational policies and procedures have been reviewed and updated where needed. Responsible Party: Leadership Team Monitoring: Department supervisors will complete weekly compliance audits to veri-fy adherence to internal policies.
Standard #:	22VAC40-61-200-A
Complaint related:	Yes
Description:	Based upon participant record review, staff record review, and staff interview, the center failed to ensure there was at least one staff person on duty providing direct care and supervision for every six participants in care. Evidence: 1. In an interview with the LI on 4/2/2025, staff 1 confirmed that one CNA staff was used for kitchen duties a majority of their shift. 2. On 4/2/2025, the LI observed staff 3 in the kitchen preparing and serving meals. In an interview with the LI, staff 3 stated that they were scheduled 7:30 a.m. to 3:30 p.m. Staff 3 stated that from 7:30 a.m. to10:00 a.m., they were preparing and serving breakfast as participants arrived. Staff 3 stated that lunch preparation and clean-up was completed between 11:30 a.m. and 2:00 p.m. Staff 3 stated that at 2:30 p.m., they begin preparing snacks to be served around 3:00 p.m. Staff 3 confirmed that they are available to assist participants if it?s an emergency; however, stated that when it?s not emergency care, they are only in the kitchen. 3. The Punch-In/Punch Out Reports, Timesheets, and Daily Attendance Logs were reviewed for the months of January 2025, February 2025, and March 2025. The CNA calendar detailing staff assignments was reviewed for January 2025 and March 2025. 4. Out of 17 program days for January 2025, there were 17 days that the 1:6 staff ratio was not met by the center. The highest attendance was recorded on March 24, 2025. On March 24, 2025, there were 55 participants recorded on the Daily Attendance Log. The punch-in/punch-out report for March 24, 2025, indicated that there were seven (7) scheduled staff. The CNA calendar for March 2025 assigned staff 7 to the kitchen. 5. Out of 18 program days for February 2025, there were 17 days that the 1:6 staff ratio was not met by the center. The highest attendance was recorded on February 25, 2025. On February 25, 2025, there were 59 participants recorded on the Daily Attendance Log. The punch-in/punch-out report and individual timesheets for February 25, 2025, indicated that there were five (5) scheduled staff. 6. Out of 21 program days for March 2025, there were 21 days that the 1:6 staff ratio was not met by the center. The highest attendance was recorded on January 24, 2025. On January 24, 2025, there were 59 participants recorded on the Daily Attendance Log. The punch-in/punch-out report and individual time sheets for January 24, 2025, indicated that there were four (4) staff clocked in. The CNA calendar for January 2025 assigned staff 7 to the kitchen. 7. In an interview the with the LI, staff 1 confirmed there was not enough staff performing direct care and supervision to meet the 1:6 staff ratio.
Plan of Correction:	*Corrective Action Taken: An immediate recruitment campaign was implemented to hire additional qualified staff members to meet the state requirements that there shall be at least one staff person on duty providing direct care and supervision for every six participants in care, or portion thereof, whether at the center or on field trips. *Systemic Change: To improve staff retention IMCC will evaluate and enhance em-ployee engagement and satisfaction programs.HR will collaborate with the Executive Director to maintain proper staffing ratios *Responsible Party: HR and Executive Director *Monitoring: Review and adjust staff scheduling procedures to ensure staffing levels meet regulatory requirements.
Standard #:	22VAC40-61-200-C
Complaint related:	Yes
Description:	Based upon participant record reviews, staff record reviews, and staff interviews, the center failed to ensure that there were additional staff persons available to support the assessed functional levels and current needs of the participants. Evidence: 1. In an interview with the Licensing Inspector (LI) on 4/2/2025, staff 4 stated that they are short staff across the board. Staff 4 stated that it was challenging because they have participants with behaviors. Staff 4 stated that the sole focus was meeting care needs, therefore activities and prevention of incidents was not being done. 2. In an interview with the LI, staff 1 provided email documentation of incidents reported by staff that occurred while they were short staffed. 3. In an email dated 3/7/2025 from staff 7 to staff 1, staff 2, staff 5, staff 8, and staff 9, staff 7 writes ??. [participant 2] picked up [participant 3]. I was the only staff member in the room?In addition to that, [participant 2] was very touchy with [participant 4] ?I understand we are short on staff, especially today, but I feel that being the only true staff member in a combined room is extremely dangerous. The care staff and other recreation staff were toileting or running participants to the front?? 4. In an email dated 2/25/2025 from staff 4 to staff 1, staff 2, staff 5, staff 9, and staff 10, staff 4 writes ?Just wanted to give some feedback on [participant 5] ? [participant 5] is going to fall. In the afternoon?s [participant 5?s] body is so tired that [participant 5] walks with [participant 5?s] knees bent. I don?t want [participant 5] to fall, but sometimes I am by myself while the girls are toileting?? 5. In an email 02/27/2025 from staff 4 to staff 1, staff 2, staff 5, staff 8, and staff 9, staff 4 writes ?I am writing another email about [participant 6]. [participant 6] was playing with the blind cords in Coral and wrapped them around [participant 6?s] neck?I was by myself as the CNA was toileting participants?? 6. In an email dated 3/5/2025 from staff 4 to staff 1, staff 2, staff 5, staff 9, and staff 10, staff 4 wrote ?Hi, I just wanted to reach out about [participant 7?s] behaviors?[participant 7 needs the one on one, but we can?t do that here?Also, [participant 7] was yelling, hitting, and scratching me?In the afternoons, I am by myself for the most part?? 7. In an interview with the LI, staff 5 provided a list of residents with high care needs including challenging behaviors, two-person assist, or two-person transfers. The list included nine (9) residents with documented challenging behaviors including participant 5, participant 6, and participant 7.
Plan of Correction:	*Corrective Action Taken: An immediate recruitment campaign was implemented to hire additional qualified staff members to meet the state requirements that there shall be at least one staff person on duty providing direct care and supervision for every six participants in care, or portion thereof, whether at the center or on field trips. *Systemic Change: To improve staff retention IMCC will evaluate and enhance em-ployee engagement and satisfaction programs. Responsible Party: HR and Executive Director Monitoring: Review and adjust staff scheduling procedures to ensure staffing levels meet regulatory requirements.
Standard #:	22VAC40-61-280-B
Complaint related:	Yes
Description:	Based upon participant record review and staff interview the center failed to ensure supervision of participant schedules, care, and activities along with attention to specialized needs such as prevention of falls and wandering. Evidence: 1. In an interview with the LI on 4/3/2025, staff 3 stated that about a year ago a participant broke their shoulder due to an incident that occurred while they were short staffed. 2. In an incident report for participant 1, the description of event states ?[participant 1] attempted to stand up out of [participant 1?s] chair and lost [participant 1] balance. Staff witnessed [participant 1] losing [participant 1?s] balance and attempted to reach [participant 1] but were unable to stop [participant 1?s] fall.? An update to the incident report included a progress note written by staff 4 on 6/24/2024 that states ??There is an acute, mildly displaced and impacted fracture left proximal humerus surgical neck?? 3. The Daily Attendance Log for 6/21/2024 states there was 37 participants on site. There were four (4) scheduled direct care staff. 4. In an interview with the LI on 4/3/2025, staff 4 confirmed that the incident occurred due to short staffing.
Plan of Correction:	*Corrective Action Taken: Direct care staff will receive ongoing fall prevention train-ing covering risk identification, safe ambulation and fall response *Systemic Change: Care plans will be updated with individual fall prevention strate-gies. *Responsible Party: Director of Nursing and Director of Social Services *Monitoring: A fall tracking log will be maintained and reviewed monthly by Clinical Team and Director of Social Services.