VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hunters Woods at Trails Edge
2222 Colts Neck Road
Reston, VA 20191
(703) 429-1130

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: April 25, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 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:

To ensure that the facility has a thorough understanding of the standards, the licensing inspectors had a discussion with the executive director, the director of wellness and the associate executive director regarding the following standards: 22VAC40-73-100, 22VAC40-73-120, 22VAC40-73-440, 22VAC40-73-450-E, 22VAC40-73-530-C, 22VAC40-73-640 and 22VAC40-73-990.

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 04/25/2024 7:41AM until 4:00PM 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: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: morning medication administration, noon-time meal, medication cart audit An exit meeting will be 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1180-B
Description:	Based on observation of the facility?s physical plant, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: At approximately 8:17AM during the walk through of the facility?s memory care unit, there was an operable long-stem lighter with an orange base located in the unlocked top far right drawer of the cabinet on the same wall as the refrigerator in the country kitchen which is accessible to residents. This was also observed by staff person 4.
Plan of Correction:	Executive Director conducted a mandatory all staff meeting on ordinary objects or materials that may be harmful to residents. A full and thorough inspection of each resident?s apartment and common areas were conducted during the meeting by the Executive Director, to ensure any potential harmful materials or objects are removed.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organizations shall communicate and establish an agreed upon coordinated plan of care for the resident and the services provided by the hospice organization shall be included on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 2, dated 02/29/2024, indicates that the resident is receiving hospice/palliative care and that the resident is receiving end of life comfort care services through collateral 2; however, the ISP does not include information of what services are being provided by Collateral 2 to the resident. 2. Staff persons 4 and 5 verified that the resident is receiving hospice services from Collateral 2.
Plan of Correction:	Resident individualized service plan has been updated to include the hospice/ palliative care with information of services provided by the hospice team. This care plan will be updated when ever there is a change of service.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated at least once every 12 months or as needed for a change in a resident?s condition. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 02/13/2024 in the record for resident 1 has documentation that the resident has a supra-pubic catheter. The ISP dated 02/13/2024 does not have a written description of services to be provided for this identified need. The ISP also does not have any time frames listed for expected outcomes for any of resident 1?s identified needs. 2. The record for resident 5 has a signed Do Not Resuscitate Order (DNR) dated 04/16/2024. The ISP dated 04/20/2024 in the record for resident 5 does not include resident 5?s DNR status and has documentation of ?CPR? located under the photo for resident 5 on the first page. The ISP also does not have any time frames listed for expected outcomes for any of resident 5?s identified needs. 3. The ISP for resident 2, updated 02/29/2024, and the ISP for resident 3, updated 04/05/2024, do not have any time frames listed for expected outcomes for any of resident 2 or 3?s identified needs.
Plan of Correction:	Resident UAI and ISP has been updated to include time frame and outcome with services to be provided to resident 1. Code status on residents has been reviewed and corrected to reflect on their face sheet and individualized service plan with time frames.
Standard #:	22VAC40-73-610-D
Description:	Based on resident record review, staff interviews and observation of the noon-time meal, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician?s or other prescriber?s orders. EVIDENCE: 1. The record for resident 1 has physician orders signed on 10/02/2023 that include that resident 1 has been ordered a diabetic diet. The special diet book located in the facility kitchen has documentation that resident 1 is on a regular diet. Interviews by two licensing inspectors (LIs) and staff persons 8 and 9 conducted on 04/25/2024 expressed that they were not aware of the physician order for a diabetic diet for resident 1 and have been providing a regular diet to the resident. 2. The record for resident 2 has physician orders signed on 03/27/2024 that indicate for the resident?s current diet to be discontinued and to start the resident on a pureed diet with thin liquids. The special diet book located in the facility kitchen has documentation that resident 2 is on a low sodium diet with thin liquids. In addition, observation of the noon-time meal during the on-site inspection, the two LIs along with staff persons 8 and 9 observed that the resident was being served lunch entree 2 which was a chicken salad sandwich on white bread with lettuce, tomato, and onion with house made potato chips. Staff persons 8 and 9 expressed that they were not aware of the physician order for the resident to be served a pureed diet and have been providing a regular diet to the resident.
Plan of Correction:	Director of Nursing and Dining Director will ensure that residents receive diets that have been prescribed by their Physician or dietitian. Staff will ensure that when a diet is prescribed for a resident by the dietitian (and approved by NP) it shall be prepared and served according to the physician?s orders.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication carts, the facility to ensure that the facility medication management plan was implemented in regard to outdated, damaged or contaminated medications. EVIDENCE: 1. The facility medication management plan has documentation under Med 14- Outdated, Damaged or Contaminated Medications that ?2. All RMAs are to confirm expirations dates of medications during the medication pass? and under Med 22-Administering and Assisting with Injections that ?10. Note the expiration dates for injectables and discard upon expiration ?and ?11. Once an injectable medication is opened follow the expiration date according to manufacturer?s instructions?. 2. An opened Lantus Insulin pen was observed by two licensing inspectors (LIs) in the presence of staff person 5 in the memory care medication cart for resident 3. The pen did not have a date that the Insulin was opened or a date to discard the insulin to be able to follow manufacturer?s instructions which is to discard a Lantus Insulin pen 28 days following the first use.
Plan of Correction:	RMA?s and LPNs shall ensure that all medications have a manufacturing date and expiration date. All bottled medications and Insulins shall date on which they were opened to know the date they need to be discarded. Facility medication management plan has been reviewed with all RMA?s and LPN to ensure adherence to the policy
Standard #:	22VAC40-73-680-H
Description:	Based on resident record review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. EVIDENCE: 1. The record for resident 3 contains a signed physician?s order, dated 04/15/2024, for potassium chloride 20MG tablet take one tablet by mouth every day for two days for a total of two doses. 2. The April 2024 MAR for resident 3 includes documentation that the mediation was only administered on 04/18/2024 at 8:00AM. 3. Interview with staff person 5 revealed that the medication was administered to the resident per the physician?s order for a total of two doses; however, staff person 5 was unable to find MAR documentation of the second dose of the aforementioned medication that was administered to resident 3.
Plan of Correction:	Director of Nursing/ assistant Director of Nursing have in serviced all RMAs and LPNs to document all medications administered. Periodic audit of med pass and chart review shall be conducted by DON/ ADON and designee.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The records for staff person 10, date of hire 09/19/2023, and staff person 11, date of hire 08/08/2023, did not contain documentation of a criminal history record report being completed on or prior to their 30th day of employment. In an interview conducted with staff person 7 on the day of inspection, staff person 7 expressed that this was correct and that criminal history reports could not be found for these employees. 2. The record for staff person 12, date of hire 09/19/2023, has documentation of a criminal history record report being processed on 10/25/2023 but the report has documentation that the transaction is being processed. The record for staff person 12 does not have a completed criminal history record report. In an interview conducted with staff person 7 on the day of inspection, staff person 7 expressed that this was correct and that a completed criminal history report could not be found for this employee. 3. The record for staff person 13, date of hire 09/05/2023, has documentation that a criminal history record report was not completed until 11/02/2023 for this employee. 4. The record for staff person 14, date of hire 09/19/2023, has documentation that a criminal history record report was not completed until 10/30/2023 for this employee.
Plan of Correction:	A criminal record check has been run on staff 10, 11, and 12 and a copy of their completed report is placed in their respective files. The Executive Director or designee shall sign off all new hire documents to ensure that the criminal history record report for each employee is obtained on or prior to the 30th day of employment.