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

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Dec. 12, 2023

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
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

Technical Assistance:
Please submit a renewal application 30 days prior to the expiration of the current license. A new license cannot be issued without a completed renewal application.

Comments:
Type of inspection: Renewal
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 8:25 am on 12/12/2023 and exited at 3:00 pm.
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: 38
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 10
Number of staff records reviewed: 4
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch.
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.eddy1@dss.virginia.gov

Violations:
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 a safe, secure environment the licensee, administrator, or designee completed a review of the appropriateness of each resident?s continued residence in the special care unit.
Evidence:
1. The resident records for Resident 2, admitted 10/10/2022 and Resident 3, admitted 12/22/2022 did not contain the six-month review of appropriateness for continued placement in a special care unit.

Plan of Correction: All resident files will be reviewed for completion of forms per state regulation 1100-B. The Director of Nursing will monitor for compliance by updating PCC dashboard. The Executive Director will follow up on completion of this form. Resident 2 and resident 3 six-month review appropriateness for continued placement in special care unit has been corrected and updated as of 12/13/2023.

Standard #: 22VAC40-73-250-C
Description: Based upon a review of records during the renewal inspection conducted on 12/12/2023, the facility failed to ensure that the personal and social data maintained on staff and included in the staff record included an original sworn disclosure statement for two of ten staff records.
Evidence:
1. The staff record for Staff 4 did not contain a completed sworn disclosure statement.
2. The staff record for Staff 10 did not include a completed sworn disclosure statement.

Plan of Correction: All employee files have been updated to ensure compliance with state regulation 250-C-6. Executive Director and Director of Nursing will follow up with new employee files to ensure completion of original sworn disclosure statements upon hire. The Executive Director has created a spreadsheet with new employee onboarding checklist to include sworn disclosure statements. Staff 4 and staff 10 sworn disclosure statements were completed on 12/13/2023.

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.

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