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Arleigh Burke Pavilion
1739 Kirby Road
Mc lean, VA 22101
(703) 506-6900

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Feb. 6, 2020

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
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 ensure that all staff and resident tuberculosis screenings document that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. (250, 320).

Please ensure that the most updated forms for Resident Rights and Responsibilities and for ALF Disclosure Statement and all required initials and signatures are obtained.

Comments:
An unannounced monitoring study was conducted from 8:15 a.m. - 4:45 p.m. on 02/06/2020. At the time of entrance 20 residents were in care. The sample size consisted of six resident records and two discharged resident records, and three staff records. Three residents, one family member, staff and ancillary staff were interviewed. Resident, staff and volunteer records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 5/29/2019 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including wine and cheese social. Medication administration was observed with one staff and medication carts observed for PRN medications. Building and Grounds observed. Violations and risk ratings reviewed and exit interview held with Administrator and management team.

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) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:
Standard #: 22VAC40-73-410-A
Description: Based on documentation, facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives including emergency response procedures.

Evidence: Documentation of orientation for Resident #1 admitted 7/30/2019 and Resident #4 admitted on 1/03/2020 did not include emergency response procedures.

Plan of Correction: STEPS OF CORRECTIONS:
1) Resident #1 has been oriented to the facility?s emergency response procedure by admissions personnel.
2) The daughter (legal representative) of resident #1 shall be oriented to the facility?s emergency response by admissions personnel.
3) Resident #4 has been oriented to the facility?s emergency response procedure by admissions personnel.
4) The daughter (legal representative) of resident #4 shall be oriented to the facility?s emergency response by admissions personnel.
5) The emergency response procedure for the facility has now been added to the orientation checklist by the director of admissions.
MEASURES TO PREVENT REOCCURRENCE OF NON-COMPLIANCE
1) The Administrator has reeducated the Admissions team on orientation of new residents to include emergency response procedures.
2) The administrator or designee will do a complete review of all new residents? records admitted to the facility going forward.
Findings from audits will be forwarded to the QAPI for consideration and or recommendation of further action(s).

Standard #: 22VAC40-73-680-M
Description: Based on record review, observation and interview, facility failed to ensure that as needed (PRN) medication shall be available.

Evidence: During observation of medication cart, Resident #2's Mucinex ordered 12/21/2018 for PRN was not available.

Plan of Correction: STEPS OF CORRECTIONS:
1.) Resident?s #2 Mucinex was received during survey and it is now available.
MEASURES TO PREVENT REOCCURRENCE OF NON-COMPLIANCE
1) The Director of Nursing (DON) or designee will conduct an audit of physician?s orders for PRN medication and their availability.
2) New admission orders will be reviewed daily at the morning clinical meetings on weekdays to ensure availability of medications.
3) The DON or designee will complete a re-education of licensed staff on securing ordered medication, including PRN medications.
4) The DON or designee will conduct random weekly audits of medication carts for
availability of PRN medications. Findings from audits will be forwarded to the QAPI for consideration and or recommendation of further action(s).

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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