VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Willow Oaks Court
8595 Centreville Road
Manassas, VA 20110-8457
(703) 257-6280

Current Inspector: Margaret Woods-Kane (804) 724-9618

Inspection Date: Sept. 4, 2024 and Sept. 5, 2024

Complaint Related: No

Areas Reviewed:

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 GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2- (16) Protection of adults and reporting 63.2- (17) Licensure and Registration Procedures 63.2- (18) 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

Technical Assistance:

N/A

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: 9/4/2024 9:00am ? 5:45pm and 9/5/2024 8:40am ? 6:50pm 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: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication pass, lunch being served, activities, building and grounds were well maintained. Additional Comments/Discussion: Discussed with the administrator the renewal process and renewal application completion. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review and staff interview the facility failed to use the required disclosure statement form developed by the department. Evidence: 1. LI reviewed the signed disclosure statement for Resident 10 (date of admission 5/8/2024) 2. The signed disclosure statement was the previous version (02/19) and had been altered to include Section VII COVID-19. 3. LI discussed the current disclosure statement available on the DSS website with Staff 1. 4. Staff 1 acknowledged during an interview with LI on 9/4/2024 the disclosure signed by Resident 10 was outdated and altered.
Plan of Correction:	Corrective Action: The new disclosure statement was downloaded and implemented during inspection. New Measures: Facility will review DSS correspondence and website with Staff1 to ensure accuracy of forms are included in the residents? admission documents. A checklist was developed and implemented as part of the resident admission documents, which the Admissions coordinator will ensure is completed at the time of admission. An audit was conducted for all admissions in the past 12 months. All residents affected have been identified and the applicable forms will be reviewed and resigned. All audits will be reviewed in QAPI for further recommendations. By: Administrator / Admissions Coordinator
Standard #:	22VAC40-73-350-B
Description:	Based on record review and staff interview the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. Evidence: 1. LI reviewed Resident 10 (date of admission 5/8/2024) record, the sex offender check was completed on 9/3/2024. 2. Staff 1 acknowledged during interview with LI on 9/5/2024 the sex offender check was not completed prior to admission.
Plan of Correction:	Corrective Action: An audit was conducted to ensure sex offender checks were completed for all admissions in the past 12 months. A Review of admission paperwork, prior to admission will be conducted to ensure all required documents are completed. New Measures: A checklist was developed and implemented as part of the resident admission documents, which the Admissions coordinator will ensure is completed at the time of admission. All audits will be reviewed in QAPI for further recommendations By: Administrator / Admissions Coordinator
Standard #:	22VAC40-73-390-A
Description:	Based on record review and staff interview the facility failed to provide a resident agreement that included all the elements in the standards. Evidence: 1. LI reviewed Resident 9 chart (date of admission 4/9/2024). 2. LI observed a signed resident agreement (4/3/2024) that did not include an acknowledgment that the resident has been notified in writing whether or not the facility maintains liability insurance. 3. Staff 1 reviewed Resident 9 agreement and acknowledged it did not include the notification of liability insurance.
Plan of Correction:	Corrective Action: The resident facility agreement was reviewed and corrected to include information that the facility maintains liability insurance. New Measures: agreement has been updated to reflect this requirement. Conducted complete review admission paperwork to ensure all elements required by DSS were addressed. All admission agreements from the past 12 months have been reviewed, and all residents affected have been identified and the applicable forms will be reviewed and resigned. All audits will be reviewed in QAPI for further recommendations. By: Administration / Admissions
Standard #:	22VAC40-73-680-M
Description:	Based on observation, record review, and staff interview the facility failed to ensure as needed (PRN) medications were available, properly labeled for the specific resident, and properly stored at the facility for one of three residents. Evidence: 1. Licensing Inspector (LI) conducted a medication cart audit, 9/4/2024. 2. LI observed for Resident 3 (date of admission 7/7/2021) PRN Benadryl (25mg for itching) and PRN Nitroglycerine (0.4mg for chest pain) listed on the signed physician order sheet (dated 8/12/2024) missing from the medication cart. 3. Staff 3 and Staff 6 acknowledged during an interview with the LI on 9/4/2024, the medications were not in the cart.
Plan of Correction:	Corrective Action: During the time of the inspection the Benadryl and nitroglycerine PRN medications were available in the STAT box in the event of an emergency for a resident as needed, however they were not labeled for Resident #3. A review of resident orders for PRN and ensure medication is available for use along with reviewing all PRN orders for non-utilization of 30 or more days and engaged provider for direction. New Measures: Immediately a 100% in-house audit of all ALF residents and to identify PRN not utilized for 30 days or more. D/c as indicated by the MD. Ensure PRN medications are available. Staff was re-educated and will continue to receive on going education to minimize and prevent future violation reoccurrences. All audits will be reviewed in QAPI for further recommendations. By: DON, Nurse Management, L&D department.
Standard #:	22VAC40-73-830-E
Description:	Based on record review and staff interview, the facility failed to ensure a written response was provided to the resident council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns. Evidence: 1.LI requested and reviewed resident council minutes from June, July, and August 2024. 2. LI requested the facilities written response for the concerns mentioned in each of the monthly resident council minutes. 3. Staff 1 stated during an interview with LI on 9/5/2024 that concerns from the resident council meetings are reviewed but a written response with recommendations or resolutions prior to the next meeting is not provided.
Plan of Correction:	Corrective Action: Resident council concerns will continue to be documented and provided to the specific department to address the concern. New Measures: Completed resident council written concern forms will be reviewed and signed off by the Resident Council president and Vice President. A copy of the concern and resolution will be posted (for a minimum of 1 week for all residents to see to view. These will be placed with the resident council minutes. All audits will be reviewed in QAPI for further recommendations. By: Life Enrichment / Case Management
Standard #:	22VAC40-73-960-A
Description:	Based on observation and staff interview, the facility failed to have their written plan for fire and emergency evacuation approved by the appropriate fire official. Evidence: 1. LI requested (9/4/2024) the written plan for fire and emergency evacuation with the fire official?s approval. 2. Staff 1 acknowledged the plan was not approved by a fire official.
Plan of Correction:	Corrective Action: Our fire and emergency evacuation plan was sent to the fire marshal, and has been approved as of 10/15/24. New Measures: The approved copy will be placed in our emergency binder and reviewed annually like the annual review of policies. By: Administrator, Dir. of Building Services