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. 13, 2025

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 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2- (1) GENERAL PROVISIONS 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

Technical Assistance:

Allowable Variance re: Staff Record Storage Nutrition/Dietician Oversight Requirements Orientation Form

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: 02/13/2025: 8:45 AM to 3:00 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: 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: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals (Breakfast & Lunch), Medication Observation, Activities (Group Exercise & Movie) Additional Comments/Discussion: N/A 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-B-8
Description:	Based on direct observation and staff interview, the facility failed to ensure that the current license was posted at the facility in a place conspicuous to resident and the public. Evidence: 1. On 02/13/2025, the LI completed a tour of the buildings and grounds at approximately 9:00 AM and did not observe the license posted in a place conspicuous to the residents. 2. In an interview with the LI on 02/13/2025, Staff 4 stated that they would call Staff 3 to determine the location of the license. While Staff 4 was on the phone with Staff 3, Staff 4 told the licensing inspector that the license was being framed by Staff 3. 3. On 02/13/2025, Staff 1, Staff 2, and Staff 3 acknowledged that the license was not posted.
Plan of Correction:	Facility will ensure that current license is posted in a conspicuous place for resident?s and the public.
Standard #:	22VAC40-73-520-I
Description:	Based on direct observation and staff interview, the facility failed to ensure that when one activity is substituted for another, the change is noted on the written schedule of activities. Evidence: 1. During a tour of the facility, the LI observed the posted monthly activity schedule for February. The calendar listed the activities for 02/13/2025 as the following: a. 10 AM Exercise b. 11 AM Chronicles c. 2 PM Trivia d. 4PM Netflix 2. The LI observed the residents watching television starting at approximately 12:45 PM through the afternoon. 3. During the preliminary exit interview with the LI on 02/13/2025, Staff 3 confirmed that the 4:00 PM activity was started early because the residents prefer not to do highly cognitive activities right after lunch. Staff 1 and 2 acknowledged that the schedule of activities had not been changed to reflect that information.
Plan of Correction:	Facility will ensure that the daily activities calendar is updated if a given activity is changed throughout the day.
Standard #:	22VAC40-73-610-B
Description:	Based on facility document review and staff interview, the facility failed to ensure that menus for the week?s meals and snacks were posted in a place conspicuous to residents. Evidence: 1. On 02/13/2025, the LI toured the buildings and grounds around 9:00 AM and did not observe a copy of the weekly menu posted in a place conspicuous to the residents. 2. In an interview with the LI on 02/13/2025, Staff 4 stated that the menu was available and posted in the kitchen. Staff 4 stated that if residents needed to know what was on the menu, they provide the information as requested. 3. In an interview with the LI on 02/13/2025, Staff 1 and 2 acknowledged that the menu was not posted at the time of observation.
Plan of Correction:	Facility will ensure that the menu for the weeks meals and snacks will be posted in a conspicuous place for residents.
Standard #:	22VAC40-73-610-E
Description:	Based on staff interview, the facility failed to ensure that a copy of a diet manual was kept current and readily available to personnel responsible for food preparation. Evidence: 1. On 02/13/2025, the LI requested a copy of the diet manual. 2. In an interview with the LI on 02/13/2025, Staff 1 retrieved a folder containing articles and guidance provided by the dietician. Staff 1 confirmed that there was not a current diet manual readily available.
Plan of Correction:	Facility will that it has a diet manual on hand and readily available for food service personnel.
Standard #:	22VAC40-73-640-A
Description:	Based on document review and staff interview, the facility failed to ensure that the medication management plan addresses procedures for administering medications and includes all required components. Evidence: 1. On 02/13/2025, upon request, Staff 1 provided a copy of the medication management plan. The medication management plan did not include: a. Methods for monitoring medication administration and the effective use of the MARs for documentation; b. Methods to ensure that MARs are maintained as part of the resident?s record; c. Methods to ensure that staff who are responsible for administering medication are adequately supervised; d. Methods to ensure that residents do not receive medication or dietary supplements to which they have known allergies; e. Methods to ensure that staff who are responsible for administering medications are trained on the medication management plan; and f. Procedures for internal monitoring of the facility?s conformance to the medication management plan. 2. On 02/13/2025, Staff 1 and 2 confirmed the information was not included in the medication management plan.
Plan of Correction:	Facility will ensure that the Medication management plan will be revised to include the information detailed in the ?violation evidence? reflected in the ?description of violation?, section #1, category ?A? through section ?F?. Revisions began 2.21.25, and will be formally added into the medication management plan by 3.28.25
Standard #:	22VAC40-73-680-K
Description:	Based on resident record review and staff interview, the facility failed to ensure that the facility has obtained a detailed PRN [as needed] medication order that indicates the symptoms requiring medication when medication aides administer medication and directions as to what to do if symptoms persist. Evidence: 1. Resident 1?s record contained a signed physician order summary dated 10/25/2024. The physician order summary contained a PRN order that stated the following ?TAKE ? =(0.25mg) TABLET BY MOUTH 3 TIMES A DAY AS NEEDED FOR ANXIETY.? 2. In an interview with the LI on 02/13/2025, Staff 2 confirmed that all Registered Medication Aides (RMA) who administer medications call her for consultation prior to administering narcotic medication on a PRN basis. Staff 2 acknowledged that the order did not contain specific symptoms for administration and directions as to what to do if symptoms persist.
Plan of Correction:	The facility will ensure that a list of symptoms is present on PRN medication orders for all PRN medications.
Standard #:	22VAC40-73-830-G
Description:	Based on staff interview, the facility failed to ensure that the residents were reminded annually that they can establish a resident council, and the facility will assist in its formation and maintenance. Evidence: 1. During a tour of the building with the LI, Staff 4 stated that they do not have resident?s council. 2. In an interview with the LI on 02/13/2025, Staff 1 confirmed that the facility does not have a resident?s council. 3. In an interview with the LI on 02/13/2025, Staff 2 stated that the facility does not have a reminder regarding resident?s councils given annually.
Plan of Correction:	Facility will create an internal monitoring form that tracks the annual notification to residents that they can establish a resident council, and that the facility will assist in its formation and maintenance.
Standard #:	22VAC40-80-120-E-2
Description:	Based on direct observation and staff interview, the facility failed to ensure that the most recent inspection summary was posted in a place conspicuous to the residents and the public. Evidence: 1. On 02/13/2025, the LI toured the facility and did not observe the posted copy of the most recent inspection summary. 2. In an interview with the LI on 02/13/2025, Staff 1 confirmed that the most recent inspection summary was not posted.
Plan of Correction:	Facility will ensure that the most recent inspection summary is posted in a conspicuous place for the residents and the public.