Inspection Reports for
Arleigh Burke Pavilion at Vinson Hall Retirement Community
VA, 22101
Back to Facility Profile3 Reports · 1 Summary
Inspection Summary
7 inspections covered, Jun 2021 – Jun 2026.
Inspection Reports Summary
Visit Reason
The page covers 7 inspections of Arleigh Burke Pavilion by the Virginia Department of Social Services from June 1, 2021 to June 12, 2026.
Findings
Across that history VDSS cited 5 violations under 4 distinct standards. 3 of the 7 visits ended with violations cited and 4 with none.
Violations (5)
22VAC40-73-720-A: Facility did not include DNR orders in the individualized service plan.
22VAC40-73-450-E: Individualized service plan not signed and dated by required parties.
22VAC40-73-260-A: Direct care staff member lacked current first aid certification documentation.
22VAC40-73-450-C: Facility failed to have a comprehensive individualized service plan for residents in care.
22VAC40-73-450-C: Comprehensive individualized service plan lacked written description of services and providers.
Report Facts
Violations cited: 5
Distinct standards: 4
Inspections on page: 7
Inspections with violations: 3
Complaint visits: 0
Individual Reports
One document per inspection visit.
Inspection Report — Jan 15, 2025
Complaint Investigation
Date: Jan 15, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to provide timely discharge notifications, bed hold notices, baseline care plan summaries, implementation of care plans, medication administration per physician orders, respiratory care, and monitoring of anticoagulant medications.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to provide discharge notifications, bed hold notices, baseline care plan summaries, proper care plan implementation, medication administration errors, inadequate respiratory care, and lack of anticoagulant monitoring. Substantiation status is not explicitly stated.
Findings
The facility failed to provide written discharge notifications and bed hold notices for Resident #15, failed to provide baseline care plan summaries for Residents #35 and #36, failed to implement care plans for Residents #42 and #18, failed to provide proper respiratory care for Resident #141, and failed to monitor anticoagulant therapy for Residents #3, #6, #11, #18, and #22. Multiple interviews and record reviews confirmed these deficiencies with minimal harm or potential for harm to residents.
Violations (9)
Failed to provide written notification of discharge reasons to Resident #15.
Failed to provide bed hold notice at discharge for Resident #15.
Failed to provide baseline care plan summaries for Residents #35 and #36.
Failed to implement comprehensive care plan for Residents #42 and #18.
Failed to position Resident #42 in proper body alignment.
Failed to provide restorative nursing/maintenance services for Resident #42.
Failed to provide respiratory care in a sanitary manner for Resident #141 by not storing incentive spirometer properly.
Administered Amlodipine outside physician-ordered parameters for Resident #18 multiple times.
Failed to monitor anticoagulant therapy as ordered for Residents #3, #6, #11, #18, and #22.
Report Facts
Residents in survey sample: 25
Dates of medication administration outside parameters: 10
Medication dosage: 5
Anticoagulant dosage: 2.5
Anticoagulant dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Interviewed regarding failure to provide written discharge notification and baseline care plan summaries. | |
| OSM #1 (Social Services Manager) | Interviewed regarding discharge notification responsibilities. | |
| ASM #1 (Administrator) | Informed of multiple concerns including discharge notification, bed hold notices, care plan implementation, and medication administration. | |
| ASM #2 (Director of Nursing) | Informed of multiple concerns including discharge notification, bed hold notices, care plan implementation, and medication administration. | |
| ASM #4 (Senior Director of Clinical Services) | Informed of multiple concerns and provided statements regarding restorative care and anticoagulation monitoring. | |
| ASM #5 (Chief Operating Officer) | Informed of multiple concerns. | |
| LPN #1 | Interviewed regarding anticoagulant monitoring and medication administration. | |
| OSM #3 (Physical Therapist) | Interviewed regarding Resident #42 positioning and therapy recommendations. |
Inspection Report — Aug 11, 2022
Complaint Investigation
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely written notification to the resident's responsible party and Ombudsman upon hospital transfer, and failure to evidence a current dialysis contract with an outside dialysis center for residents.
Complaint Details
The complaint investigation revealed that the facility did not provide written notification to the resident's responsible party and Ombudsman after a hospital transfer on 6/23/22. The facility policy did not require written notification to the Ombudsman. Additionally, the facility lacked a current dialysis contract with the outpatient dialysis center for Resident #33.
Findings
The facility failed to provide written notification to the resident's responsible party and Ombudsman for a hospital transfer of Resident #16 on 6/23/22, and the facility policy did not require written notification to the Ombudsman. Additionally, the facility failed to evidence a current dialysis contract with the outpatient dialysis center providing services to Resident #33.
Violations (2)
Failure to provide timely written notification to the resident's responsible party and Ombudsman before transfer or discharge, including appeal rights, for Resident #16.
Failure to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for Resident #33.
Report Facts
Residents in survey sample: 23
Date of hospital transfer: Jun 23, 2022
Date of survey completion: Aug 11, 2022
Assessment Reference Date: Jul 25, 2022
Assessment Reference Date: Jul 9, 2022
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ASM #1, Director of Nursing and Acting Administrator | Stated no documentation of written notices and was aware of dialysis contract issue | |
| OSM #1, Social Services Manager | Stated no written notification provided to responsible party for hospital transfers and Ombudsman only notified for discharges to home or other long term care |
Inspection Report — Jul 7, 2021
Routine
Date: Jul 7, 2021
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal and state regulations regarding resident privacy, food safety, infection control, and sanitation practices.
Findings
The facility was found deficient in maintaining resident privacy during blood pressure checks, proper food storage and dishwashing temperatures in the kitchen, and infection control practices including hand hygiene and disinfection of reusable blood pressure cuffs between residents.
Violations (3)
Failed to provide privacy for two residents when obtaining blood pressure readings in the dining room.
Failed to store and prepare foods in a sanitary manner; food items were not labeled with opening dates and dishwashing machine rinse temperatures were below required levels.
Failed to maintain infection control practices by not washing hands or using sanitizer and not disinfecting reusable blood pressure cuffs between residents.
Report Facts
Residents in survey sample: 23
Residents affected by privacy deficiency: 2
Residents affected by infection control deficiency: 4
Dishwashing machine temperature runs observed: 5
Dishwashing machine temperature out of range dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in privacy and infection control deficiencies related to blood pressure readings |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding cleaning and disinfection procedures for blood pressure cuffs |
| OSM #3 | Director of Dining Services | Interviewed regarding food storage and dishwashing temperature monitoring |
| OSM #4 | Dietary Aide | Observed operating dishwashing machine and unaware of temperature monitoring procedures |
| ASM #1 | Administrator | Made aware of findings during inspection |
| ASM #2 | Director of Nursing | Made aware of findings during inspection |
4 CMS Surveys
CMS Survey — Jan 15, 2025
Jan 15, 2025
CMS Survey — Jul 8, 2021
Jul 8, 2021
CMS Survey — Aug 11, 2022
Aug 11, 2022
CMS Survey — Jan 15, 2025
Jan 15, 2025
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