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Purcellville Home Assisted Living Facility Inc.
16764 Hillsboro Road
Purcellville, VA 20132
(703) 336-9236

Current Inspector: Jamie Eddy (703) 479-5247

Inspection Date: Dec. 21, 2016

Complaint Related: No

Areas Reviewed:

Technical Assistance:
Please be aware that effective July 1, 2016 each facility employee must report in writing to his employer if he is convicted of an offense as defined in Virginia Code 63.2-1719 AND employees must annually complete a sworn disclosure statement disclosing any criminal convictions or pending criminal charges, whether within or outside the Commonwealth of Virginia. Providers are encouraged to update or to develop employment policies to include this information. Additionally effective October 19, 2016 the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers, 22VAC40-90, was revised to add a requirement that assisted living facilities and adult day care centers not continue to employ any person who has a conviction of any of the barrier crimes.

An unannounced renewal study was conducted from on 12/21/16. At the time of entrance four residents were in care with one staff person present. An additional staff person arrived approximately 20 minutes into the inspection. The sample size consisted of two resident records, two staff records and one individual interviews. Resident and staff records and other documentation reviewed, additional required documentation will be reviewed during the follow up inspection. Residents were observed eating breakfast and lunch and resting in their rooms. Medication was reviewed. Violation notice issued, risk ratings reviewed and exit interview held. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at

Standard #: 22VAC40-72-90-C
Description: Facility failed to ensure that blood glucose monitoring supplies are properly labelled. Based on observation 1/1 resident's glucometer and supply storage pouch are not labelled with the resident's name.

Plan of Correction: The label for the glucometer and supply storage pouch had fallen off. New label has been placed on resident?s glucometer storage pouch.

Standard #: 22VAC40-72-290-A
Description: Facility failed to ensure that a record shall be established for each staff person. It shall not be destroyed until at least two years after employment is terminated. Based in interview and observation Staff #2 did not have an established record at the facility.

Plan of Correction: The administrator will ensure that all staff records are kept at the facility.

Standard #: 22VAC40-72-320-A
Description: Facility failed to ensure that the assisted living facility shall have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychosocial well being of each resident as determined by resident assessments and individualized service plans, and to assure compliance with this chapter. Based on observation and interview 1/2 staff did not have adequate knowledge to assure compliance with this chapter. Upon the Licensing Inspector's (LI) arrival there was one staff present. The staff person was unable to direct the LI to the resident records or provide LI with information regarding the resident medications. He was unaware of what an MAR is or where to find them. Additionally, staff told LI that he was a nurse however there is no documentation to indicate that he has a nursing license. Staff indicated to LI that he was going out on break in the garage even though there was not another staff present and available to assist the four residents in the house if necessary.

Plan of Correction: There are always at least two staff members present, however, at the time of inspection one of the staff members had stepped out briefly for supplies; The facility has always ensured that there are adequate skilled/knowledgeable/qualified staffs present to fully meet the needs of the residents.

Standard #: 22VAC40-72-350-A
Description: Facility failed to ensure that a person shall have a physical examination by an independent physician, including screening for tuberculosis, within 30 days prior to the date of admission. Based on record review 1/2 resident records did not include all the required information on the physical. Resident #2 admitted on 3/27/16 admission physical did not include the following required information: Height, weight, and blood pressure; Any diagnosis or significant problems; Any recommendations for care including medication, diet and therapy. The recommendations for diet is unclear as it states Regular but then in parentheses includes Low Calorie/Low Fat.

Plan of Correction: The administrator will ensure that in future admissions the Report of physical exam for admission will contain all information prior to admission

Standard #: 22VAC40-72-430-A
Description: Facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face-to-face using the uniform assessment instrument pursuant to the requirements in Assessment in Assisted Living Facilities (22 VAC 40-745). Based on documentation review 1/2 residents did not have a complete UAI. Resident #2 admitted on 3/27/16 had a UAI in the resident record however the UAI did not include a Psycho-Social Assessment. Additionally, the UAI was not dated or signed.

Plan of Correction: The administrator has reviewed all UAIs for completeness and corrected all deficiencies.

Standard #: 22VAC40-72-460-D-1
Description: Facility failed to ensure that when care for gastric tubes is provided to the resident by unlicensed direct care facility staff as allowed in 22 VAC 40-72-340 J (ii), the following criteria shall be met: The care shall be provided by a direct care staff member who has successfully completed general and resident-specific training requirements and competencies in tube care from the delegating registered nurse, which has been documented by the nurse. Based on documentation review there is no documentation to indicate that staff have the required training to care for gastric tube feedings.

Plan of Correction: The documentation to meet the regulation 22VAC40-720-340 J (ii) has been in place to document the DCF training in tube care. However, due to absence of the administrator, the documentation was not presented to the LI.

Standard #: 22VAC40-72-560-G
Description: Facility failed to ensure that all records that contain the information required by these standards for residents shall be retained at the facility and kept in a locked area. Based on observation resident records were found unlocked in a cabinet in the Administrator's office that was not locked.

Plan of Correction: The administrator will re-enforce and ensure that all resident records are locked at all times.

Standard #: 22VAC40-72-650-A-1
Description: Facility failed to ensure that a medicine cabinet, container or compartment shall be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. The storage area shall be locked. Upon inspector's arrival 4/4 resident medications were observed in a cabinet in the medication room that was not locked.

Plan of Correction: The administrator will ensure that going forward medication storage area will be locked at all times.

Standard #: 22VAC40-72-670-B
Description: Facility failed to ensure that all medications shall be removed from the pharmacy container by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-72-660 and administered by the same staff person. Based on observation and interview medication 4/4 residents have medications being administered by an unlicensed staff person. Medications are being removed from the pharmacy issued container by a licensed med aide and placed in a pill planner for the week. An unlicensed person is then administering the medications.

Plan of Correction: There is an RMA on duty at all times at the facility. The administrator will ensure that going forward the regulation 22VAC40-72-660 is met fully.

Standard #: 22VAC40-72-670-H
Description: Facility failed to ensure that all medications administered to residents are documented on a medication administration record (MAR) including over-the-counter medications, and dietary supplements. The MAR shall include: Date and time given and initials of direct care staff administering the medication. Based on interview the staff person administering the medications is not signing the medications as given.

Plan of Correction: The administrator will ensure that MAR is signed as regulation states.

A compliance history is in no way a rating for a facility++.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.


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