VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birmingham Green Adult Care Residence-Willow Oaks Assisted Livin
8595 Centreville Road
Manassas, VA 20110-8457
(703) 257-6280

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Sept. 11, 2019 and Sept. 12, 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

Comments:

Date of Inspection: September 11 and 12, 2019; 10am to 1:30pm Type of Inspection: Renewal inspection Census 90 Number of records reviewed and interviews conducted-13 resident records, 16 employee records, 11 interviews. If you have any questions or email changes, please do not hesitate to contact me at ken.koontz@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. All previous self-reported incidents were reviewed at this time

Violations:

Standard #:	22VAC40-73-30
Description:	Based on interviews, observations and chart review, it was determined the facility failed to have a program of care that adequately provided protection and supervision to the residents. Evidence: Over the past 90 days the facility had three additional resident to resident altercations with one requiring one resident to be sent to the emergency department. Resident A and B were reportedly the aggressors in the three events.
Plan of Correction:	In response to the actions taken to address the number of resident to resident incidents the following, however not limited to actions have been implemented: ? Staff posted strategically in each corridor when not in a resident room to engage with residents. ? Weekly Resident Empowerment session conducted by psychologist, Dr. Lebedun. ? Peer:Peer groups. ? Rotation of social work interns for support services. ? Review of residents that may be better served in another setting is in the process. ? Behavior management plans are in place and being put into place when needed, which includes action steps if not followed. ? Purposeful rounding. ? Involvement of the interdisciplinary team for service plans and engagement (environmental; facilities; nursing; administration?). ? Identification and review of triggers for proactively addressing behaviors.