VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Poet's Walk of Leesburg
102 Desmond Plaza
Leesburg, VA 20175
(571) 224-9516

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Feb. 8, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

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: LI entered the facility at 6:30 am on 2/8/2023 and exited at 10:23 am on 2/8/2023. 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 2/2/2023 regarding allegations in the area(s) of resident care and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI observed residents eating breakfast. LI observed residents rooms. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-710-E
Complaint related:	Yes
Description:	Based upon observations made by LI and review of resident records, the facility failed to meet the following condition in using a physical restraint in a nonemergency situation: 1. Restraints shall be used in accordance with the resident?s service plan, which documents the need for a restraint. Evidence: LI observed Resident #4 sitting in a high-back wheelchair with a belted seatbelt around her waist on 2/8/2023 at approximately 9:45 am. The Individualized Service Plan for Resident #4 did not document the requirement of a physical restraint.
Plan of Correction:	Resident #4 is under hospice care, and it was discovered that the hospice agency provided the wheelchair/seatbelt. On 2/8/23, DON notified hospice that the seatbelt was being removed (which it was, by the Maintenance Director). An audit was then completed by DON on all other wheelchairs in the community, to ensure that no other seatbelts were attached. DON will re-educate hospice agencies on Standard Number 710. On 2/8/23, Interim Executive Director educated all Leadership staff on Standard Number 710. All Leadership staff are aware that seatbelts are not permitted in the community. Going forward, all medical supplies delivered to the community on behalf of any outside healthcare agency will be inspected by a member of the Leadership team prior to being permitted in a Resident?s room.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based upon inspection of the physical plant and interview with staff, the facility failed to ensure that the interior of the buildings shall be maintained, in good repair, and kept clean. Evidence: At approximately 6:50 am LI (licensing inspector) observed fresh feces on the wall and floor outside Room 307. LI interviewed Staff #2, who indicated someone would be contacted to clean up the feces. At approximately 7:20 am, LI observed that the feces had been clean up outside of Room 307. LI observed dried feces in the carpet outside of Rooms 401 and 408 at approximately 6:58 am.
Plan of Correction:	The fresh feces were cleaned up by staff immediately. The dried feces were cleaned by Housekeeping staff, while LI was on the premises. On 2/9/2023, the Maintenance Director deep cleaned all community carpets. Maintenance Director will continue to perform regular cleanliness checks. On 2/8/23, Leadership staff were re-educated on the expectation of addressing any unsanitary conditions that appear in the community (if you see it, clean it immediately). All other staff will be re-educated on the expectation that it is everyone?s responsibility to keep the community clean and sanitary. Lead Med Tech from each shift will be tasked with conducting regular cleanliness checks during each shift. Ongoing; Staff re-education by 2/28/23.