VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arleigh Burke Pavilion
1739 Kirby Road
Mc lean, VA 22101
(703) 506-6900

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: May 25, 2022 and May 27, 2022

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness

Comments:

Date of Inspection: May 25 and 27, 2022 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 20 Number of records reviewed and interviews conducted- 3 resident records and 3 staff records, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during lunch and activities. The Licensing Inspector reviewed the following documents during the inspection: fire drills, healthcare oversight, dietician report, activity calendar and emergency preparedness drills. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have a comprehensive Individualized Service Plan (ISP) for residents in care. Evidence: Resident A, B and C did not have documentation of a comprehensive ISP to address hospice care, bedside rails and Home Health therapies.
Plan of Correction:	The Director of Nursing and/or designee will ensure that all identified needs of residents on the UAI have a corresponding written description of what services will be provided to address identified needs. Director of Nursing and/or designee will ensure each ISP is reviewed and updated annually or if there is a change in the resident's condition to include the assessed needs as per the UAI. Community will continue to complete the preliminary ISP and comprehensive ISP in conjunction with the resident and family while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include the type of assistance needed. The Administrator and /or designee will complete random monthly audits of a minimum of 5 comprehensive ISPs to ensure ongoing compliance.