Click Here for Additional Resources
Search for an Assisted Living Facility
|Return to Search Results | New Search |

Paul Spring Independent and Assisted Living Community
7116 Fort Hunt Road
Alexandria, VA 22307
(703) 768-0234

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Oct. 12, 2021

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 BUILDING AND GROUNDS

Comments:
A non-mandated complaint inspection was initiated on 10/12/21 and concluded on 12/20/21. A complaint was received by the department regarding allegations in the areas of: Admission, Retention, and Discharge of Residents; Resident Care and Related Services; and Building and Grounds. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted on-site observations at the facility on 10/12/21, 11/15/21, and 12/13/21.

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

Violations:
Standard #: 22VAC40-73-460-B
Complaint related: Yes
Description: Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.
Evidence: Call bell reports (June 2021 ? August 2021) were reviewed during the inspection. There were 24 instances when staff members took longer than 30 minutes to respond to Resident #2?s call bell. There was one instance when staff members took longer than 30 minutes to respond to Resident #3?s call bell.

Plan of Correction: Facility will monitor call response times on a weekly basis to ensure a prompt response to resident needs. Clinical Services Director will conduct weekly review of call response times in the community. Outliers will be assessed with appropriate interventions as necessary.

Standard #: 22VAC40-73-460-H
Complaint related: Yes
Description: Based on record review, the facility failed to ensure personal assistance and care are provided to each resident as necessary so that the needs of the resident are met.
Evidence: Evidence: Resident #2?s UAI, dated 5/1/21, states that she needs mechanical and physical assistance for bathing. The bath log indicated that Resident #2 was not bathed from 6/2/21 ? 6/18/21. The log indicates that there were six resident refusals during that time period. No information was included in the resident record to explore the reasons for the continued refusals or if the resident needed additional supports to have the bath completed.
Resident #3?s UAI, dated 5/21/21, states that she needs mechanical and physical assistance for bathing. The bath log indicated that Resident #3 was not bathed in June or August, and that she only had one bath in July. The log indicates that Resident #3 refused bathing assistance 12 times in June, seven times in July, and eight times in August. No information was included in the resident record to explore the reasons for the continued refusals or if the resident needed additional supports to have the bath completed.

Plan of Correction: Facility will document bathing refusal in resident EHR. Continued refusals will be communicated to physician and responsible party to identify additional support needed. Staff in-service to be conducted with CNAs to report to Charge Nurse for documentation. Nurse will document refusals and offer alternatives

Standard #: 22VAC40-73-560-E
Complaint related: Yes
Description: Based on record review, the facility failed to ensure that the resident record is kept current.
Evidence: Resident #1?s record contained a hospital discharge document, dated 7/19/21. The document stated that the resident needed a diet consistent with carbohydrate and heart healthy, and that the resident needed all meals to be supervised. The discharge document also states that home nursing is required for skilled assessment including cardiopulmonary assessment and dietary education for disease management and dietary instruction. Resident #1?s UAI, dated 5/13/21, states that the resident eats meals without assistance. Resident #1?s physical exam, dated 3/24/21, states that the resident eats a regular diet. No documentation was found in the resident record to update Resident #1?s need for a new diet, meal supervision, or that the required home nursing was received by Resident #1.

Plan of Correction: Clinical Services Director will review all hospital readmissions prior to return to community for appropriateness and new orders. Clinical Services Director will reassess resident upon return to community for any clinical changes.

Standard #: 22VAC40-73-580-F
Complaint related: Yes
Description: Based on record review, the facility failed to ensure that residents are weighed at least monthly.
Evidence: Weight records (June 2021 ? August 2021) were reviewed during the inspection. Resident #1?s record did not contain weight documentation for the months of June and July. Resident #3?s record did not contain weight documentation for the months of June, July, or August.

Plan of Correction: Facility will conduct an audit of residents at risk for weight loss to be conducted by Clinical Services Director or designee by 1/28/22. Residents identified through audit will be weighed monthly. Significant weight loss and routine weights will be reviewed by Dietician quarterly. Any and all recommendations will be followed as ordered.

Standard #: 22VAC40-73-680-D
Complaint related: Yes
Description: Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence: Resident #2?s Metoprolol Tartrate, ordered 4/24/21, was to be held when the resident?s Systolic Blood Pressure (SBP) is less than 110 or when her heart rate (HR) is less than 60. Resident #2?s Metoprolol Tartrate was given on 6/16/21 (6 PM administration) when the resident?s SBP was 109. The medication was also given on 7/12/21 (9 AM administration) when the resident?s heart rate was 58.

Plan of Correction: Clinical Services will conduct mandatory training for all nurses and med techs regarding best practices for medication administration. The Director of Clinical Services and Assistant Director of Clinical Services will conduct routine, unannounced medication administration audits for monitoring and observation.

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.

Google Translate Logo
×
TTY/TTD

(deaf or hard-of-hearing):

(800) 828-1120, or 711

Top