VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heatherwood Independent and Assisted Living
9642 Burke Lake Road
Burke, VA 22015
(703) 425-1698

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: May 25, 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 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 5/25/23. At the time of entrance, 96 residents were in care. Meals, medication administration, and an activity were observed. Building and grounds were inspected. 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 #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Each direct care staff member shall receive certification in first aid within 60 days of employment. Evidence: The record of Staff #2, hired 2/6/23, was reviewed during the inspection. Staff #2's record did not contain first aid certification, at the time of the inspection.
Plan of Correction:	100% audit of first aid certifications to be completed and Staff #2 will have certification completed by 06/30/2023. ED, DON, and ADON will audit certification expiration dates monthly to obtain renewed certifications timely.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the administrator or their designee, and by the resident or his/her legal representative. Evidence: Resident #6's ISP, dated 1/28/23, was reviewed during the inspection. Resident #6's ISP was not signed by the resident or her legal representative. Resident #10's ISP, dated 8/23/22, was reviewed during the inspection. Resident #10's ISP was not signed by the resident or her legal representative.
Plan of Correction:	100% Resident ISP audit to be completed. ISP for Resident #6 and #10 signatures received on 06/07/2023. ED, DON, and ADON will perform routine audits to ensure signature is obtained on ISP's completed each month.
Standard #:	22VAC40-73-860-I
Description:	Based on record review and observation, the facility failed to keep cleaning supplies and other hazardous materials in a locked area. Evidence: At approximately 9:55 AM, cleaning powder was observed to be unlocked and unattended in a cabinet of the facility's game room. At approximately 10:10 AM, odor counteractant concentrate was observed to be unlocked and unattended in the physician's office.
Plan of Correction:	Cleaning supplies removed and stowed in a secure environment on 5/26/2023. Inservice conducted on 6/2/23 to Housekeeping and Environmental team regarding storage of cleaning products. ED, MOD, and Housekeeping team will perform routine rounds to verify compliance with chemical safety storage.
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 record checks, of new staff members, were observed during the inspection. Criminal record reports were not included in the records of Staff #5 (hired 9/27/22), Staff #6 (hired 10/3/22), or Staff #7 (hired 7/15/22). No documentation was provided, during the inspection, to indicate that the criminal record reports of Staff #5, #6, or #7 were received within 30 days of their employment.
Plan of Correction:	100% audit completed on 06/06/2023. ED will review all new hire employee files and ensure Criminal record reports are filed immediately upon receiving report.