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: Aug. 3, 2023 , Aug. 15, 2023 and Aug. 16, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/3/23 (5:45pm ? 6:10pm), 8/15/23 (4:50pm ? 6:50pm), 8/16/23 (1:00pm ? 4:30pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the licensing office on 6/28/23; regarding Staffing and Supervision, and Resident Care and Related Services. Resident meals, resident records, building and grounds, and facility documentation were observed. An exit meeting was held. The evidence gathered during the investigation supported some, but not all of the allegations; the area of non-compliance was: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-480-E
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that rehabilitative services and other pertinent information is documented in the resident record. Evidence: Resident #1 and Resident #2 were ordered to receive skilled services for wounds. No documentation was included in the resident record, at the time of the inspection, to document the wound care services that Residents #1 (ordered 6/11/23) and #2 (ordered 6/30/23) received. Facility documentation included weekly skin / wound reports, but the reports do not indicate that the wound treatment was provided by a rehabilitative professional, the service provider?s initial service date, or (if any) aftercare instructions provided to staff.
Plan of Correction:	The Director of Nursing has reached out to the rehabilitative professional preferred provider and informed them that they must document in the resident's record the initial service date, and aftercare instructions to be provided by Tall Oaks staff. As mentioned in the description of violation, the community has a weekly skin/wound report that has progress information, updates, initials from the person providing services, and date of the services. This document is required by Tall Oaks and the management company as a part of the Quality Assurance reports submitted on a monthly basis.