VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Beverly Assisted Living
3408 Beverly Drive
Annandale, VA 22003
(571) 308-3793

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Dec. 13, 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 32.1 Reported by persons other than physicians 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. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

Documentation was discussed with the provider.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/13/23 (8:50 AM - 1:44 PM) 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: Six The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Four Number of interviews conducted with residents: Two Number of interviews conducted with staff: Two Observations by licensing inspector: Meals, medication administration, activity An exit meeting was conducted to review the inspection findings. 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 #:	22VAC40-73-530-A
Description:	Based on observation and interview, the facility failed to ensure that any resident who does not have a serious cognitive impairment is allowed to freely leave the facility. A resident who has a serious cognitive impairment shall be subject to the provisions set forth in 22VAC40-73-1040 A or 22VAC40-73-1150 A. Evidence: Facility staff reported that Resident #3 resides on the first level of the building. The facility?s elevator was not operational, at the time of the inspection. At the time of the inspection, the first level?s exit door was locked. The door had a double-cylinder deadbolt, that would require a key to disengage the lock (whether from the interior or the exterior of the building). At the time of the inspection, Resident #3 was the only resident on the first level of the building. Resident #3 was not able to use the elevator to reach another level of the home, and there was no alternate method to reach the other levels of the building. The only exit door for the first level of the building required a key to disengage the lock. Resident #3's physical exam, 8/25/23, does not indicate that he has a serious cognitive impairment. The facility does not have a special care unit.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area remains locked. Evidence: At approximately 11:35 AM, the medication cart was observed to be unlocked and unattended.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-I
Description:	Based on documentation and interview, the facility failed to ensure that elevators are inspected at least annually. Evidence: The facility's elevator was not operational, at the time of the inspection. The facility?s administrator reported that an error code was flashing on the elevator's level indicator. No elevator certificate of inspection was provided, to confirm that the elevator had been inspected within the past year.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-950-E
Description:	Based on documentation, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. Evidence: The last documented review on the emergency preparedness plan, observed during the inspection, was dated 12/15/22. The review as more than six-months old, at the time of the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure that a fire and emergency evacuation drawing is posted in a conspicuous place on each floor of each building used by residents. Evidence: The facility?s fire and emergency evacuation drawing was not posted, in a conspicuous place, on the first or second floor of the building. The facility?s fire and emergency evacuation drawing was observed in three of the eight bedrooms, but no drawing was observed in an area conspicuous to all residents, staff, and visitors.
Plan of Correction:	Not available online. Contact Inspector for more information.