VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Wellington at Lake Manassas
7820 Baltusrol Blvd
Gainesville, VA 20155
(703) 468-2750

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Feb. 28, 2023

Complaint Related: No

Areas Reviewed:

Administrative and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments

Comments:

Date of Inspection: 2/28/23 and 3/2/23 Type of Inspection: Monitoring inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@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 102 Number of records reviewed and interviews conducted- 8 records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. 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). The completed corrective action needs to be in the licensing office by March 13, 2023

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, it was determined that the Individualized Service Plan did not identify all the resident's needs or services provided. Evidence: Resident C's Individualized Service Plan did not include her need to be spoon fed, use bedrails or that she was receiving mental health services.
Plan of Correction:	Resident C's Individualized Service Plan has been reviewed and updated to reflect the current needs of the resident. The Wellness Director will review UAI's and ISP's for active residents to ensure accuracy of the service plan and update as needed. The Wellness Director will be responsible for the monitoring of this corrective action and will report any areas of ongoing noncompliance to the Executive Director.