VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Jefferson
900 North Taylor Street
Arlington, VA 22203
(703) 516-9455

Current Inspector: Alexandra Roberts

Inspection Date: Jan. 12, 2023

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.

Comments:

An unannounced renewal inspection was conducted on 1/12/23 (8:20 AM ? 5:45 PM). At the time of entrance, 51 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 eight resident records and four staff records. Violations were discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that each resident received an annual tuberculosis risk assessment, as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The record for Resident #7 was reviewed during the inspection. Resident #7?s record contained a chest x-ray, dated 4/2/21. The chest x-ray way was the most recent completed risk assessment, included in the record for Resident #7. A TB risk assessment note, dated 3/28/22, was observed in Resident #7?s record, but the risk assessment was not signed as being completed.
Plan of Correction:	The TB risk assessment for Resident #7 dated 3/28/22 was reviewed by the nurse and signed at the time of the survey and a new TB risk assessment was completed on 1/25/23. Annual TB risk assessments were audited by the ALC to verify that a completed and signed assessment dated within the past year is present on each resident?s record. If missing or incomplete risk assessments were identified, a new tuberculosis risk assessment was initiated. The ALC or her designee will audit the records of all residents due for TB risk assessment monthly for the next three months to verify that annual tuberculosis risk assessments are completed, signed, and filed on resident records. Over the next three months, the results of these audits will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of three months, the QAPI committee will reevaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-650-E
Description:	Based on record review, the facility failed to ensure that the resident record contains the physician?s signed written order. Evidence: Resident #4?s record was reviewed during the inspection. Resident #4?s record contained unsigned orders (dated 12/16/22) to discontinue Vitamin D, Rosuvastatin, Calcium, Multivitamin, and Acetaminophen. The record also contained an order (dated 12/16/22) to change the dosage of Resident #4?s Seroquel from 50mg to 75mg at bedtime. Resident #7?s record was reviewed during the inspection. Resident #7?s record contained unsigned orders (dated 12/22/22) for Morphine and Lorazepam. Resident #7?s record also contained an undated, and unsigned, order form for Levsin, Dulcolax, and Tylenol.
Plan of Correction:	The unsigned orders for residents #4 and #7 were re-faxed to the physician for signature by the hospice physician, pending response. Orders for the last 3 months were audited for residents receiving hospice services to verify that they were signed timely by the physician or physician representative. If unsigned orders were identified, they were faxed to the physician for signature. Refresher training will be provided by the RCD to nursing staff by 2/2/23 regarding the requirement to obtain signatures on physician orders within 14 days. The RCD or her designee will audit the orders of three randomly selected residents on hospice services weekly for the next month, then bi-weekly for two months, to validate that physician orders were signed within 14 days. The results of these random audits will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: PRN Flonase, ordered 1/6/23 for Resident #2, was not available for administration at the time of the medication cart audit. Facility staff confirmed that Resident #2?s Flonase was not present, at the time of the medication cart audit. PRN Senna, ordered 7/2/21 for Resident #9, was not available for administration at the time of the medication cart audit. Facility staff confirmed that Resident #9?s Senna was not present, at the time of the medication cart audit.
Plan of Correction:	The Flonase ordered for resident #2 was refilled on 1/12/23. The Senna ordered for resident #9 was refilled on 1/14/23. PRN medication orders were audited by the LPN Night Supervisor to verify that medications were available for administration. Medications with orders that were not found on the cart were either refilled or discontinued if no longer needed. Refresher training will be provided by the RCD to medication staff by 2/2/23 regarding the process for reordering medications that are depleted. The Administrator or her designee will audit five randomly selected PRN medication orders weekly for the next month, then bi-weekly for two months, to validate that medication is available for administration. The results of these random audits will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.