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: May 14, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated 5/4/2020 and concluded on 5/14/2020. A complaint was received by the department regarding allegations in the area of standard 940. The administrator was contacted by telephone to conduct the investigation. Interviews with the Loudoun County Fire Marshal were also conducted as part of the inspection. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. 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 email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-940-B
Complaint related:	No
Description:	Based upon interviews with administrator, memory care director, and with the local fire marshal's office, the facility failed to ensure compliance with local fire ordinance. Evidence: The facility violated section 1031.2 of the Loudoun County Fire Prevention Code by blocking the exit from a patients' room with tension gates or furniture. The tension gates and furniture were used to prevent residents on the memory care unit, who frequently wander, from accessing areas out side of their rooms and thus prevent those residents from being exposed or potentially exposing other residents to COVID 19.
Plan of Correction:	Removal of all tension gates and furniture completed on 5/14/2020. Staff Development Coordinator or designee will ensure that 100% of assisted living staff are educated that no tension gates or furniture can be used to restrict resident's freely exiting their apartments or moving throughout the neighborhood. Education completion by 6/1/2020. Neighborhood manager or designee will complete weekly environmental audit of neighborhoods to ensure there are no tension gates or furniture barriers in place for 3 months beginning 5/25/2020.