VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Wellington at Lake Manassas
7820 Baltusrol Blvd
Gainesville, VA 20155
(703) 468-2750

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Dec. 19, 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: December 19, 2019; 9am to 3:00pm Type of Inspection: Renewal Census 64 9 resident charts reviewed, 7 staff charts reviewed and 9 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 The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violation(s) for this inspection.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on interviews and chart review and as part of a renewal inspection, it was determined the facility failed to ensure all staff received the required dementia training. Evidence: Four of four staff persons reviewed that had worked more than 4 months did not have documentation of attending at least 10 hours of training in cognitive impairment developed and provided by a licensed health care professional practicing within the scope of his profession who has at least 12 hours of training in the care of individuals with cognitive impairments due to dementia
Plan of Correction:	The Administrator, Business Office Manager, and Director of Resident Care will ensure that within four months of the starting date of employment in the safe, secure environment, direct care staff attends at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of the State Board of Social Services Standard for Licensed Assisted Living Communities and RUI Human Resources Policies and Procedures Manual. The Administrator and Business Office Manager will ensure that a licensed health care professional practicing within the scope of his profession has at least 12 hours of training in the care of individuals with cognitive impairments due to dementia or who has been approved the VDSS to provide training.
Standard #:	22VAC40-73-710-C
Description:	Based on observations, interviews and chart review and as part of a renewal inspection, it was determined the facility failed to maintain the required oversight when a restraint was used. Evidence: Residents B and C were observed with bedrails. Both residents on the secured unit. Staff stated the rails were used to assist with mobility, but the resident were unable to explain why the rails were in place. The facility did not provide the required oversight of a restraint, including but not limited to: ? Be imposed in accordance with a physician's written order that specifies the condition, circumstances, and duration under which the restraint is to be used ? Restraints shall only be applied by direct care staff who have received training in their use as specified by subdivision 2 of 22 VAC 40-73-270; ? The facility shall closely monitor the condition of a resident with a restraint, which includes checking on the resident at least every 30 minutes; ? The facility shall assist the resident with a restraint as often as necessary, but no less than 10 minutes every hour, for his hydration, safety, comfort, range of motion, exercise, elimination, and other needs; ? Direct care staff shall keep a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems. ? Restraints shall be used in accordance with the resident's service plan, which documents the need for the restraint and includes a schedule or plan of rehabilitation training enabling the progressive removal or the progressive use of less restrictive restraints when appropriate; ? Before the initial administration of a restraint, the facility shall explain the use of the restraint and potential negative outcomes to the resident or his legal representative and the resident's right to refuse the restraint and shall obtain the written consent of the resident or his legal representative;
Plan of Correction:	The Director of Resident Care will maintain adherence to 22 VAC 40-73-710 standard and its subsections and maintain oversight that restraints are imposed in accordance with a physician's written order that specifies the condition,circumstances, and duration under which the restraint is to be used. The Director of Resident Care will ensure that a resident is able to explain the reasons for the use of a restraint. The Director of Resident care will ensure written documentation of all communications is maintained in a resident?s record.
Standard #:	22VAC40-73-750-B
Description:	Based on observations and interviews as part of a renewal inspection, it was determined the facility failed to require a bed for each resident. Evidence: Resident A had the box springs and mattress on the floor, without a bed. The Director of Resident Care stated this was to assist with injuries associated with a possible fall. The facility has requested a low bed, but the family has reportedly declined.
Plan of Correction:	The Director of Resident Care will follow the VDSS standard, 22 VAC 40-73-750, to ensure that a resident is required to have a complete bed set, to include a bed frame, box spring and mattress unless the resident, POA, or responsible party declares in writing that he does not wish to have an item or items listed in subsection B of this section and understands that he may decide otherwise at any time. The Director of Resident Care will ensure and maintain written specification in the resident's record.