VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Culpepper Garden III INC
4439 N. Pershing Drive
Arlington, VA 22203
(703) 528-0162

Current Inspector: Alexandra Roberts

Inspection Date: Sept. 14, 2023

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Mixed Population

Comments:

Date of Inspection: September 14, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@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 69 Number of records reviewed and interviews conducted- 9 records (both staff and residents), 7 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 Licensing Inspector observed the residents at lunch and activities. The Licensing Inspector reviewed the following at the time of inspection: resident council reports, activity calendars, menus, fire drills, dietician report and healthcare oversight.

Violations:

Standard #:	22VAC40-73-250-B
Description:	Based on staff record review and staff interview, it was determined that the facility failed to have a staff record at the facility as required. Evidence: Staff Z's record was not at the facility as required.
Plan of Correction:	An audit was conducted to ensure all employee files were on site within the community.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have a coordinated plan of care between the hospice agency and the facility on the Individualized Service Plan (ISP). Evidence: Resident Bs ISP had no documentation of a coordinated plan of care between the hospice agency and the facility as required.
Plan of Correction:	An audit has been conducted for all residents receiving hospice services to ensure coordination of hospice care. ISPs for residents receiving hospice services have been reviewed and updated to reflect the coordination of care on each resident's individualized ISP.