VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Aug. 17, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 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

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:25 am on 8/17/2022 and exited the facility at 4:30pm on 8/17/2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-970-A
Description:	Based upon a review of records, the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia State Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: According to the fire drill reports, during the previous quarter (April, May, and June of 2022) fire drills were conducted during the 3rd shift twice and the 2nd shift once. During the first quarter of 2022, (January, February, and March) fire drills were conducted during the 1st shift twice and the 2nd shift once.
Plan of Correction:	1. Unable to correct past event where facility failed to conduct a fire drill on the 3rd shift in the first quarter of 2022, and on 1st shift during the second quarter of 2022. 2. Security Manager and/or designee provided in service education to ensure fire and emergency drills required for each shift in a quarter are not conducted in the same month. 3. Security Manager/designee reviewed current quarter drills and determined we are in compliance with standard 970-A. 4. Security Manager/designee will monitor drills are conducted during each shift, every quarter, and will bring results to QAPI.