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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: June 1, 2021 and June 2, 2021

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
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.

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 renewal inspection was initiated on 6/01/2021 and concluded on 6/02/2021. The administrator was contacted by telephone for an entrance interview to initiate the inspection. The administrator reported that the current census was 19. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records and two staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete.

Exit interview was conducted with the administrator and the director of nursing on 6/14/2021.

Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

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, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed.

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 #: 22VAC40-73-450-C
Description: Based on record review, facility failedto ensure that the comprehensive individualized service plan shall include a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.

Evidence: An order dated 5/06/2021 was observed in record for Resident #1 for PT/OT and the need, service and responsible provider was not documented on the Individualized Service Plan dated 5/6/2021.

Plan of Correction: With respect to the specific residenUsituation cited: Based on record review, facility failed to ensure that the comprehensive individualized service plan shall include a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.

Resident #1 had a PT/OT order dated 5/6/2021, not indicated on the ISP. ISP has been updated to include the refusal of services.
The Clinical Manager and/or designee will audit all resident records to ensure residents receiving supplemental services is clearly documented in the ISP.
Interdisciplinary team will also review the ISP with the resident and family during the care plan meeting to ensure accuracy.

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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