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Ashby Ponds, Inc.
21160 Maple Branch Terrace
Ashburn, VA 20147
(571) 291-6210

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 28, 2021 and Sept. 8, 2021

Complaint Related: No

Areas Reviewed:
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
A non-mandated monitoring inspection was initiated on 7/28/2021 and concluded on 9/8/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation.

The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found in the violation notice.

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 e-mail at jamie.eddy@dss.virginia.gov.

Violations:
Standard #: 22VAC40-73-460-D
Description: Based upon a review of records and interview the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence:
1. A review of the facility?s incident report, resident records, and interview with Staff #1, on 7/22/2021 at approximately 10:00 am, an employee allowed Resident #1 to exit the memory care unit through the secured doors. According to the incident report provided by the facility ?Resident #1 approached an Ashby Ponds programming assistant at the main door to the Memory Care neighborhood at approximately 10:00 am and stated she was leaving; the programming assistant did not recognize Resident #1, assumed she was a family member and let her (Resident #1) off the neighborhood. The programming assistant then inquired with a care associate who the individual was, providing a visual description and the care associate stated it was a resident. The programming assistant immediately left the neighborhood and went to look for Resident #1. When she (the programming assistant) reached the first floor she encountered Resident #1 near the elevators and was being assisted by two staff members.? According to interview with Staff #1, at approximately 10:05 am, Resident #1 was escorted back to the memory care neighborhood.
2. According to the resident record, the facility?s incident report, progress notes, and interview with Staff #1, Resident #1 was unable to be located on the memory care unit at approximately 9:20 am on 7/24/2021. The incident report states ?the resident was identified as missing at approximately 9:37 am and as staff began to initiate a search, they received a phone call from the concierge that the resident had been located and was at the main club house. The resident was safely escorted back by security to the secured neighborhood at approximately 10:45 am.? According to the incident report, ?the resident was being supervised from the time she was located until the time she returned to the neighborhood.? The progress notes indicate that two independent living residents noticed Resident #1 outside of the building and accompanied her to the Cardinal House (which is a club house on the campus).

Plan of Correction: 1. Programming Assistant received immediate education on 7/22/2021 on Resident Elopement and her role in ensuring resident safety.
2. Memory Care Resident Admission notification process was updated. The notification will include distribution of a current Resident photograph to the Continuing Care Leadership Team via email. Leadership Team to post photograph in their designated staffing areas to ensure all staff are aware of the new admission. Completion by 10/10/2021.
3. Comprehensive staff education:
a. Memory Care Manager or designee will ensure that Continuing Care Leadership receive education regarding the updated notification process and their role in ensuring resident safety. Completion by 10/10/2021.
b. Department Manager or designee will ensure that their staff receive education regarding education regarding the updated notification process and their role in ensuring resident safety. Completion by 11/10/2021.
c. Staff Development Coordinator or designee will ensure that Continuing Care staff and Ashby Ponds Security Team receive education regarding how to respond when Memory Care doors are unsecured to ensure resident safety. Completion by 10/9/2021.
4. Memory Care Manager or designee will complete weekly audit of new memory care resident admission notifications to ensure compliance with updated process for 3 months beginning 9/10/2021.
5. One additional fire drill to be conducted beginning 9/10/2021 to monitor staff response and compliance with processes when Memory Care doors are unsecured. Completion by 12/10/2021.

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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