VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ashby Ponds, Inc.
21160 Maple Branch Terrace
Ashburn, VA 20147
(571) 291-6210

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Aug. 13, 2019 and Aug. 14, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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.

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at 703-934-1505.

Comments:

An unannounced renewal study was conducted on 8/13/19 and 8/14/19. At the time of entrance 93 residents were in care. The sample size consisted of ten resident records, two discharge records, five staff records, two volunteer records and four individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 5/13/19 were reviewed. Residents were observed eating breakfast and engaging in activities including folding baby clothes and working puzzles. Medication administration was observed. Possible violations were discussed at the exit interview. 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 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-K
Description:	Based upon a review of records, the facility failed to ensure that the use of PRN medications is prohibited, unless one or more of the following conditions exist: Medication aides administer the PRN medication when the facility has obtained from the resident's physician or other prescriber a detailed medication order. The order shall include: directions as to what to do if symptoms persist. Evidence: Not all of the "as needed" PRN medications for Residents #2, #4, and #8 included what to do if symptoms persists on the physician's or other prescriber's order.
Plan of Correction:	1. As of 8/22/2019, PRN medication orders for residents #2, #4, and #8 were corrected to include what to do if symptoms persist. 2. A 100% audit for all PRN orders will be completed by September 11, 2019, to ensure physician?s or other prescriber?s order include what to do if symptoms persist. 3. Wellness Manager or designee will ensure completion of monthly audit of 10 residents for 3 months beginning 10/11/19 to ensure what to do if symptoms persist on the physician?s order or other prescriber?s order. 4. Date to be corrected 9/11/19.
Standard #:	22VAC40-73-930-D
Description:	Based upon a review of resident records and interviews with staff, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: this inability shall be included in the resident's individualized service plan. Evidence: For Residents #4 and #6, who reside on the safe and secure unit, their inability to use the call bell system was not included on their Individualized Service Plan
Plan of Correction:	1. As of 8/22/2019, individualized service plans for residents #4 and #6 were updated to indicate their inability to use signaling device to call for assistance. 2. A 100% audit of the individualized service plans of residents who reside on the safe and secure unit will be done by September 11, 2019, to ensure it reflects their inability to use the signaling device. 3. Memory Care Manager or designee will assess resident?s ability to use a signaling device or any other services upon admission, annually during routine assessment, and/or during assessment of significant change in condition. Manager?s assessments will be documented in Individualized Service Plan. 4. Date to be corrected 9/11/19