Lavendar Hills Prince William Campus — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Lavendar Hills Prince William Campus was inspected 4 times between January 28, 2022 and August 15, 2024 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 10 violations under 10 distinct standards.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window and no longer serves any of these on its site. All 4 are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

08/31/2025

Administrator

Ms Micaela Gordon

Licensing inspector

Ishmel Paige

Inspector phone

(804) 963-0360

Approved for

Residential and Assisted Living Care · Non-Ambulatory

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

August 15, 2024Inspection1 violation

Inspection dates

Aug. 15, 2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

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: 8/15/2024 9:00am ? 12:15 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: 0 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: 1 Number of interviews conducted with residents: N/A building vacant under renovation. Number of interviews conducted with staff: 2 Observations by licensing inspector: Building vacant and under renovation. Renovation did not include structural changes, it consisted primarily of updating floors, paint, and fixtures. Additional Comments/Discussion: Building has been vacant since January 8, 2024, and undergoing renovations since March 2024. Due to the building renovation, no residents were on-site, and the majority of documentation was in storage. A discussion was conducted with Staff 2 and Staff 3 regarding assisted living standards and ensuring compliance. Provider is to notify agency when renovations are complete and to request a modification of licensure. 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

22VAC40-73-430-B

Based on record review and staff interview the facility failed to provide documentation of written notification to the resident, resident’s legal representative and designated contact person, of planned discharge and that the resident will be moved within 30 days.

Evidence

During Resident 1 and Resident 2chart review documentation of discharge to another assisted living facility was not found in the resident chart.
The LI requested documentation of written notification of discharge to the resident, legal representative, and contact person if applicable from Staff 2 and Staff 3.
Staff 2 stated on 8/15/2024 that documentation was provided to residents and families. However, documentation could not be located or provided to the LI during the inspection. Staff 2 acknowledged that the documentation could not be provided.

Plan of correction

Administrator will ensure that all discharged resident files contain a discharge statement and notification form. Administrator will audit all discharged resident files monthly to ensure compliance. Administrator will ensure all files are corrected by 11/14/24

August 17, 2023Inspection7 violations

Inspection dates

Aug. 17, 2023 and Aug. 18, 2023

Areas reviewed

Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed Population

Comments

Date of Inspection: August 17 and 18, Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 17 Number of records reviewed and interviews conducted- 8 records (staff and residents), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meals and activities. The Licensing Inspector reviewed the following at the time of inspection: Healthcare Over Sight, fire drills, first aid kits, menus, activity calendars, health department and fire marshal reports. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations

22VAC40-73-1070-B

Based on direct observation by the Licensing Inspector, it was determined that the facility staff failed to have materials that may be harmful to the residents inaccessible.

Evidence

The cleaning care was at the end of the 100 hall outside a resident's room. The cleaning supplies were not in sight or supervision of any staff.

Plan of correction

Administrator/Designee provided re-education to the Team Member(s) on housekeeping duty on 8/17/23 and 8/24/23 regarding the proper storage of materials that may be harmful to residents. Administrator/Designee to perform weekly audits for q3 months and at random moving forward in order to ensure adherence to VDSS Standards.

22VAC40-73-440-H

Based on resident record review and staff interview, it was determined that the facility staff failed to have current reassessments of the Uniform Assessment Instruments (UAI) within the resident files.

Evidence

There was no documentation of current UAIs in resident records: Resident As UAI was dated June 23, 2022, Resident Ds UAI was dated March 8, 2022, Resident Es UAI was dated March 9, 2022 and Resident Fs UAI was dated April 18, 2022.

Plan of correction

Administrator/ Designee to conduct full Resident Record audits by 9/15/2023 in order to ensure that the Resident Records include current reassessments of Uniform Assessment Instruments. Administrator/Designee to perform random dit thl UAI f Resident Record audits monthly regarding UAIs for q3 month and at random moving forward to ensure adherence to VDSS Standards.

22VAC40-73-560-E

Based on resident record review and staff interview, it was determined that resident records were not kept current as required.

Evidence

Resident A, B, C, D, E, and F had no current documentation in the record.

Plan of correction

Administrator/Designee to conduct full Resident Record audits by 9/15/2023 in order to ensure that the Resident Records include current documentation. Administrator/Designee to perform random Resident Records audits monthly, for q3 months and at random moving forward to ensure adherence to VDSS Standards.

22VAC40-73-660-A-1

Based on direct observation by the Licensing Inspector, the medication cart that was in the front hall directly across from the front door was left open and unsecured.

Evidence

The medication cart was left unsecured and unattended in the main lobby of the facility.

Plan of correction

Administrator/Designee provided re-education to the RMA on duty on 8/17/2023. Administrator/Designee to provide re- education to all Licensed Medication Staff by 8/25/2023 regarding proper storage of mediations. Administrator/Designee to perform proper Medication Cart Storage audits weekly for q3 and at random moving forward in order to ensure adherence to VDSS Standards.

22VAC40-73-940-A

Based on facility record review and staff interview, it was determined that the facility failed to comply with the Virginia Statewide Fire Prevention Code with an annual inspection.

Evidence

The facility had documentation of an annual inspection for April 6, 2022. This was not current as required.

Plan of correction

Administrator/Designee provided re-education to pertinent Team Members on 8/18/2023 regarding compliance with the Virginia Statewide Fire Prevention Code requiring at least an annual inspection by the appropriate fire official and retention of said reports. Fire Department inspection was completed on 8/23/2023. Administrator/Designee to monitor annually and as needed for Fire Safety VDSS Standard adherence.

22VAC40-73-980-B

Based on direct observation by the Licensing Inspector and the Administrator, it was determined that the facility failed to have a complete first aid kit in the facility motor vehicle.

Evidence

The facility motor vehicle did not have a complete first aid kit as required.

Plan of correction

Administrator/Designee obtained a complete first aid kit on 8/23/2023 and placed it inside the facility motor vehicle. Administrator/Designee to perform monthly audits moving forward to ensure that the first aid kit is present, located in a designated place, containing the required items as noted by VDSS Standards.

22VAC40-73-990-C

Based on facility record review, it was determined that the facility failed to have documentation of exercises in which the procedures for resident emergencies are practiced.

Evidence

the facility records had no documentation of resident emergency drills every six months as required.

Plan of correction

Administrator/Designee to ensure that all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced by 8/24/2023. Administrator/Designee to ensure the moving forward this training is performed at least once every six months as required by VDSS Standards.

August 18, 2022Inspection2 violations

Inspection dates

Aug. 18, 2022 and Aug. 22, 2022

Areas reviewed

Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuildings and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Serious Cognitive ImpairmentMixed Population

Comments

Date of Inspection: August 18 and 22, 2022, 8:45am-3pm Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 19 Number of records reviewed and interviews conducted- 13 records (staff and resident), 7 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The residents were observed during breakfast and lunch. Also, the residents were observed during activities. Medication administration was observed. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations

22VAC40-73-450-D

Based on resident record review and staff interview, it was determined that the facility failed to have documentation of a coordinated plan of care between the facility and the hospice agency on the Individualized Service Plan (ISP) as required.

Evidence

Resident A had no coordinated plan of care on the ISP dated June 15, 2022.

Plan of correction

Resident A's ISP will have documentation reflecting the coordinated plan of care between the Hospice agency and the facility. All residents receiving hospice services will have a record audit to ensure compliance.

22VAC40-73-450-F

Based on resident record review and staff interview, it was determined that the facility failed to document a change in condition on the Individualized Service Plan (ISP) as required.

Evidence

Resident A had no documentation on the ISP dated June 15, 2022 of the mechanical soft diet ordered by the physician.

Plan of correction

Resident As ISP will have current documentation to show the mechanical soft diet ordered by the physician. All resident charts will be audited to ensure that any changes have been captured and documented.

January 28, 2022Inspection0 violations

Inspection dates

Jan. 28, 2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

Date of Inspection: January 28, 2022 Type of Inspection: Initial Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 18 Licensing Inspector (LI) conducted an announced initial inspection on January 28, 2022. The Licensing Inspector walked the physical plant, verified window and room measurements, reviewed policies and procedures and staff records and tested the call bell system. All inspections have been completed. Evacuation Posting will be updated. No violations cited today and exit interview held.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.