VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cobbdale Assisted Living 2
10617 Elmont Court
Fairfax, VA 22030
(571) 414-1850

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Feb. 16, 2024

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

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: 2/16/24 (8:50 AM - 1:40 PM). Number of residents present at the facility at the beginning of the inspection: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration 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 #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff person, on or within seven days prior to the first day of work, submits the results of a tuberculosis risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Each staff member, required to be evaluated, shall annually submit the results of a tuberculosis risk assessment. Evidence: The tuberculosis risk assessment for Staff #3, hired 8/9/23, was dated 8/16/23. Staff #3's tuberculosis risk assessment was completed after her first day of work at the facility. Facility staff confirmed that Staff #3's tuberculosis risk assessment was not completed before her first day of work at the facility. The most recent tuberculosis risk assessment for Staff #2 was dated 10/30/23. Staff #2's risk assessment form indicated that there were no tuberculosis symptoms present, but the findings of the risk assessment were not documented on the form.
Plan of Correction:	Facility will ensure that the provider performing staff TB tests indicates the result in all places where it needs to be indicated on the TB form. Facility staff will ensure all proper boxes are checked, and no incomplete information is present in staff files.
Standard #:	22VAC40-73-520-I
Description:	Based on observation and interview, the facility failed to ensure that activity substitutions are noted on the activity schedule. Evidence: The facility's activity schedule included Exercise (10 AM), Daily Chronicles (11 AM), and Michelle Birthday (1 PM). Residents were observed watching television at 10 AM, 11 AM, and 1 PM. No changes were made to the posted activity schedule, to reflect the changes in the activities that were going to be offered.
Plan of Correction:	The facility will list substitute activities on the activities calendar, so that residents who decline the activity offered at a given time, will have another option of activity available to them.
Standard #:	22VAC40-73-710-B
Description:	Based on record review and interview, the facility failed to ensure that physical restraints are only used (i) as a medical/orthopedic restraint for support, according to a physician's written order and with the written consent of the resident or his legal representative or (ii) in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others. Evidence: Side rails were observed on the beds of Residents #3 and #4. The physical examination reports of Residents #3 and #4 state that the resident has a dementia diagnosis. Resident #3's record included an individualized service plan (ISP), dated 1/25/24, that stated that he needs a two person assist with a hoyer lift for transfers. Resident #3's record contained an order, dated 2/1/24, stating that he may have side rails on a hospital bed to assist with care, rolling and ADLs in bed. The order was not signed by the physician and Resident #3's ISP did not include any information about his ability to independently use the side rails as an assistive device. Facility staff confirmed that Resident #3's independent use of the side rails was not documented on his ISP. Resident #4's record contained an order, dated 2/9/24, stating that it was ok for her to have rails on her hospital bed. Neither the order, nor Resident #4's ISP (dated 11/29/23) included information about the resident's ability to independently use the side rails as an assistive device. Resident #4's ISP states that she needs the total assistance of two staff members and a hoyer lift for transfers. Facility staff confirmed that Resident #4's independent use of the side rails was not documented on her ISP. No emergencies, involving Resident #3 or Resident #4, were reported during the inspection.
Plan of Correction:	Residents who use side rails for assistive purpose will have their ISP's updated to reflect that. Orders will also be obtained, and kept within each resident's chart, for those residents who use side rails for assistance.