VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tall Oaks Assisted Living
12052 N. Shore Drive
Reston, VA 20190
(703) 834-9800

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: March 10, 2022

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced renewal inspection was conducted on 3/10/22. At the time of entrance, 91 residents were in care. Meals, medication administration and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at M.Massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that direct care staff members maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment. Evidence: The record for Staff #4, hired 12/30/21, was reviewed during the inspection. The record for Staff #4 contained a nurse aide certification. No documentation was provided, during the inspection, to indicate that Staff #4 received first aid certification within 60 days of being hired.
Plan of Correction:	The community will ensure that all employees are trained in 1st Aid within 60 days of hire. This particular employee was hired 64 days, was registered to attend the training held on 3/10/22, completed the training, and certification was in hand on 3/10/22. Due to COVID-19 in person trainings that are approved by DSS have been challenging.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to ensure that the uniform assessment instrument (UAI) is completed at least annually. Evidence: The record for Resident #1 was reviewed during the inspection. Residents #1's UAI was dated 2/26/21. Resident #1's UAI was more than a year old, on the date of the inspection. Facility staff reported that the UAI may have been updated and was located in a different area of the facility. The updated UAI was not in the resident's chart and no additional documentation was provided, during the inspection, to verify that Resident #1's UAI was updated annually. The record for Resident #3 was reviewed during the inspection. Resident #3's UAI was dated 1/22/21. Resident #3's UAI was more than a year old, on the date of the inspection. Facility staff reported that the UAI may have been updated and was located in a different area of the facility. The updated UAI was not in the resident's chart and no additional documentation was provided, during the inspection, to verify that Resident #3's UAI was updated annually.
Plan of Correction:	The DON and ADON will ensure that all UAI's are updated and completed at least annually and as there is a change in condition. There will continue to be monthly audits to ensure all UAI's are current. In this particular incident the updated UAI was completed, however it was not in the resident's medical chart at the time of the survey.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to ensure that individualized service plans (ISPs) are reviewed and updated at least once every 12 months. Evidence: Resident #3's record was reviewed during the inspection. Resident #3's record contained an ISP, dated 1/22/21. Resident #3's ISP was more than a year old, on the date of the inspection. Facility staff reported that the ISP may have been updated and was located in a different area of the facility. The updated ISP was not in the resident's chart and no additional documentation was provided, during the inspection, to verify that Resident #3's ISP was updated annually.
Plan of Correction:	The DON, ADON, and ED will ensure that all of the Resident ISP's are updated at least annually and ensure that the updated documentation is filed in the resident's chart. This particular resident's care plan was updated and mailed out to the POA prior to the 12 month update requirement, however the POA did not return prior to the date of the inspection. There is documentation (via email) indicating that the DON and POA were in communication prior but due to COVID-19 the family had not returned or scheduled a review.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and record review, the facility failed to ensure that medication storage is limited to an out-of-sight place in the rooms of residents whose UAIs indicate that the residents are capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. Evidence: Several pill bottles and packages were observed in the room of Resident #5. Resident #5's UAI, dated 10/2/21, states that the resident needs his medication administered/monitored by a lay person.
Plan of Correction:	The community's nurses and/or med techs will continue to monitor resident rooms for any over the counter medications, including but not limited to, supplements, and ensure proper storage and administration is provided. The charge nurses, ADON, and DON consistently monitor and oversee the residents to ensure that the medications are administered as prescribed, however there are instances where the residents and/or their family members purchase supplements and over the counter medications without the facility's knowledge. Upon discovery of these supplements they were immediately removed, the primary care physician was consulted, and appropriate actions were taken.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and 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: Medication administration for Resident #11 was observed during the inspection. Resident #11's Carbidopa-Levodopa was administered during breakfast. Resident #11's Carbidopa-Levodopa order, dated 1/13/21, called for the medication to be administered 30 minutes before meals.
Plan of Correction:	The charge nurses, ADON, and DON will ensure that all medications and treatments are administered or performed per the physicians' orders or instructions. These are and will continue to be audited on a monthly basis and compared to the Physician order sheets. In this particular situation, the medication in referenced, the ADON and DON consulted with the resident's attending physician as well as the hospice provider and the order was updated during the inspection. The clarification that was discussed resulted in the order changing to indicate that the medication could be given at any time during the meals, before, or after the meals.