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 15, 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.

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced renewal inspection was conducted on 3/15/23 (8:30 AM ? 6:00 PM). At the time of entrance, 96 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. 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 #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that a review of continued appropriateness, is completed six months after a resident is placed in the safe, secure environment. Evidence: The record for Resident #3, admitted 8/2/22, was reviewed during the inspection. Resident #3's record contained a review of continued appropriateness, dated 12/1/22. Resident #3's record did not contain a review of continued appropriateness, six months after the resident was placed in the safe, secure environment.
Plan of Correction:	Resident moved into Assisted Living and transitioned to Memory Care on 8-2-22, as indicated in the description from the inspector. A review of the Continued Appropriateness form was completed. The resident had a change in condition and warranted an updated review, which was completed on 12-2-22, four months after admission. Moving forward the Director of Nursing, Assistant Director of Nursing, or designee will ensure that the review of the continued appropriateness form is completed 6 months after admission, then annually after.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that the physical examination report includes all of the required information. Evidence: Resident #3's physical examination, dated 8/1/22, did not include the resident's reaction to a known allergen (Zithromax). Resident #5's physical examination, dated 5/20/22, did not include the resident's reaction to a known allergen (Shellfish). Resident #6?s physical examination, completed April 2022, did not include documentation about the resident?s allergies and reactions, as that section of the form was left blank. Physician?s orders indicated that Resident #6 is allergic to ACE inhibitors.
Plan of Correction:	The Director of Admissions, Director of Nursing, Assistant Director of Nursing, or designee will ensure that the Health & Physical forms are completed to include, but not limited to, any known allergies.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure that DNR orders are included in the individual service plan. Evidence: Resident #5's ISP, dated 6/18/22, did not include the resident?s DNR order (signed 6/20/22). Resident #5's ISP states that the resident is Full Code.
Plan of Correction:	Resident (#5) moved in with full code status. The ISP was completed the day the resident moved in. A change in code status was completed 6-20-23, as indicated in the description of violation. Moving forward the Director of Nursing, Assistant Director of Nursing, or designee, will ensure that all ISP?s are updated when there is a change in condition, level of care, or change in code status.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report, from the Department of State Police, within 30 days of hiring an employee. Evidence: The criminal history record reports, of new staff members, were reviewed during the inspection. Staff #6 was hired 11/8/22. The criminal history record report, for Staff #6, was completed on 3/15/23. The criminal history record report was not obtained within 30 days of Staff #6's hire date.
Plan of Correction:	From the time of the previous inspection there were 17 new employee hires, and all but this employee received a criminal history background check. As soon as the Executive Director noticed, he conducted the criminal background check and self-reported to the inspector. Moving forward a criminal history background check will be completed within 30 days of hire by the Executive Director, Business Office Manager, or designee.