Poet's Walk of Leesburg
102 Desmond Plaza
Leesburg, VA 20175
(571) 224-9516
Current Inspector: Jacquelyn Kabiri (703) 397-3017
Inspection Date: Oct. 25, 2022
Complaint Related: No
- Areas Reviewed:
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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
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
22VAC40-80 THE LICENSING PROCESS
- Comments:
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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 8:20 am on 10/25/2022 and exited at 3:30 pm on 10/25/2022.
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: 57
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and 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) 479-5247 or by email at jamie.eddy@dss.virginia.gov
- Violations:
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Standard #: 22VAC40-73-440-A Description: Based upon a review of records, the facility failed to ensure that the Uniform Assessment Instrument for all residents of and applicants to assisted living facilities be completed prior to admission.
Evidence: According to records, Resident #1 was admitted to the facility on 10/14/2022. The resident record for Resident #1 did not contain a completed UAI.Plan of Correction: UAI for Resident #1 has been completed by Director of Nursing (DON) on 10/25/2022. An audit of new move ins will be completed weekly by a member of the leadership team to ensure compliance with the standard.
Standard #: 22VAC40-73-680-I Description: Based upon a review of records and inspection of the medication bubble packet, the facility failed to ensure that the Medication Administration Record (MAR) include the following: date prescribed and initials of direct care staff administering the medication.
Evidence: 1.The MARs for Residents #1, #2, #3, and #4 do not include the date medications were prescribed.
2.On 10/23/2022, the staff member administering medication to Resident #4 at approximately 2:00pm failed to initial on the MAR that the medication was administered. A review of the medication bubble packet provided evidence that the medication was administered.Plan of Correction: 1. We are looking into how we can add dates via PCC. If unable to do so electronically, dates will be added manually.
2. Training will be provided for all current and new med techs (MTs) on a quarterly basis. Audits of MAR will be done monthly by a leadership team member.
Standard #: 63.2-1720-C-2 Description: Based upon a review of records, the facility failed to ensure compliance with Section 63.2-1720 of the Code of Virginia that requires all employees of assisted living facilities and adult day care centers, as defined by Section 63.2-100 of the Code of Virginia, to obtain a criminal history record report from the Department of State Police.
Evidence: The criminal history record reports contained in the records for Staff #3 through #11 were not obtained from the Department of State Police.Plan of Correction: A Virginia State Police (VSP) application is in process and is being prepared to be sent in for approval and account establishment. All background checks will be done from June 2022 forward per direction of surveyor.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.