VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chantilly Heights
3925 Downs Drive
Chantilly, VA 20151
(703) 810-3992

Current Inspector: Ishmel Paige (804) 963-0360

Inspection Date: Oct. 16, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80 Complaint Investigation

Comments:

Type of inspection: ?Complaint? Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/16/2024, 3:15 p.m. to 4:17 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/27/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: Licensing Inspector viewed the dining room seating area and facility policies for feeding residents. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017, or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-560-E
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure all resident records were kept in a locked area. Evidence: 1. On 10/16/2024, at approximately 3:50 pm, the licensing inspector (LI) observed the medication cart, with a computer on top of the cart, in the facility?s kitchen and dining room area. The LI observed the computer screen open with resident information displayed. 2. The computer screen displayed 16 residents? photos and room numbers. 3. Staff 1 confirmed the medication cart computer screen was open to public view. 4. Photo taken as evidence.
Plan of Correction:	Med Techs received refresher training regarding locking the screen when away for any reason as well as continued assurance all drawers are locked on med carts as well.