VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emilia Assisted Living of Ashlawn Court
6533 Ashlawn Court
Springfield, VA 22150
(703) 417-9324

Current Inspector: Alexandra Roberts

Inspection Date: Sept. 19, 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 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

Comments:

Type of Inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/19/23 (8:20 AM - 11:30 AM). The acknowledgement of inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meal, Medications 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 #:	22VAC40-73-40-B-3
Description:	Based on documentation and interview, thefacility failed to ensure the criminal history record report is obtained, on or prior to the 30th day of employment for each staff member. Evidence: Staff #3 was hired on 4/30/23. Staff #3's record contained a letter from the Virginia State Police, dated 5/5/23, that indicated that a different search form would need to be completed in order to receive the criminal history record for Staff #3. No documentation was provided, during the inspection, to indicate that the facility attempted to obtain Staff #3's criminal history report after receiving the 5/5/23 letter from the Virginia State Police.
Plan of Correction:	Staff 3's criminal background check will be re-submitted by first week of October. The letter from VSP will be followed and requirements will be submitted if needed. An update will be given to the licensing inspector if report has been finally received OR if other situations arise.
Standard #:	22VAC40-73-520-I
Description:	Based on observation and documentation, the facility failed to ensure that the activity calendar is updated if one activity is substituted for another. Evidence: Residents were observed in their rooms at 10 AM. Residents were observed completing a puzzle, watching television, and resting. The activity calendar indicated that a Calisthenics activity was going to be conducted at 10 AM. No change was made to the activity calendar, to reflect the change in the activities that were going to be offered.
Plan of Correction:	This director will ensure that scheduled activities will be followed throughout the day. An alternative activity book will be created which will list the options of alternative activities per day if residents does not want to join the scheduled activity. The Ashlawn home manager is tasked to complete the project by the end of October, 2023 and activities, with alternative option will be ready by the first week of November of this year.
Standard #:	22VAC40-73-670-2
Description:	Based on record review and interview, the facility failed to ensure that an applicant, for registration as a medication aide, does not act as a medication aide on a provisional basis for longer than 120 days. Evidence: Facility staff reported that Staff #2 administered medication for several residents on the date of the inspection. Staff #2's record contained documentation that indicated that her provisional medication aide status began in June 2022. Staff #2's record contained documentation that the staff member is medication technician in Maryland. No documentation was provided, during the inspection, to confirm that Staff #2 is a registered medication aide in Virginia.
Plan of Correction:	Per Inspector?s recommendation, all medications will ONLY be given by RMA or RN, or staff on RMA training without license but within the 120 provisional days. Employees with certification will be retrained by the director (who's also an RN) to ensure that this regulation will be met.
Standard #:	22VAC40-73-680-H
Description:	Based on observation and documentation, the facility failed to ensure that information is documented on the medication administration record (MAR), at the time medication is administered. Evidence: Facility staff reported that Staff #1 and Staff #2 administered medications, on the date of the inspection. Only Staff #1's initials appeared on the MAR. Facility staff reported that resident medications are punched out of their medication cards in accordance with the day of the month. Resident #3's Levothyroxine was documented on the MAR as being given by Staff #1 on 9/19/23. Resident #3's Levothyroxine was still in her medication card for the 19th day of the month. Resident #4's Primidone (7AM and 11 AM administrations) were documented as being given by Staff #1 on 9/19/23. Resident #4's Primidone medication cards still contained the 7AM and 11 AM doses.
Plan of Correction:	RMAs will be educated to properly document medication administration and to ensure that medication is given at the right time and date. RMA's will also be reminded to double check the MAR before leaving their shift to ensure proper documentation. RMA's will receive a retraining on how to retrieve medications properly from the med cards, and to constantly document at the back of the resident?s MAR, if a medication was pulled from a different date, and the reason why this happened.
Standard #:	22VAC40-73-950-E
Description:	Based on documentation, the facility failed to ensure that a semi-annual review on the emergency preparedness and response plan was conducted with all staff, residents, and volunteers. Evidence: No documentation was provided, during the inspection, to indicate that a semiannual review of the facility's emergency preparedness plan was conducted with all staff, residents, and volunteers.
Plan of Correction:	This director will review the policy on emergency preparedness and response plan semi-annual review requirement and will initiate a meeting with the home managers. A form will be created for documentation. The facility will have a semi annual review by the end of October, 2023.