Inspection Reports for Pivotal Senior Services & Assisted Living in Springfield
VA, 22150
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Inspection Report
Renewal
Census: 6
Deficiencies: 4
Mar 27, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection found multiple violations related to staffing designation, posting of staff certifications, posting of the person in charge, and elevator inspection compliance. Plans of correction were submitted and issues were resolved or addressed.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that there was a designated direct care staff member in charge on the premises. |
| Facility failed to ensure that a listing of all staff with current certification in first aid or CPR was posted and readily available. |
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to ensure that elevators were inspected at least annually; the current elevator inspection expired 1/6/2024. |
Report Facts
Number of residents present: 6
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Elevator inspection expiration date: Jan 6, 2024
Inspection Report
Complaint Investigation
Census: 3
Deficiencies: 0
Jul 25, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-07-09 regarding allegations related to discharge practices at the facility.
Findings
The investigation did not support the allegation(s) of non-compliance with standards or law. However, violations unrelated to the complaint were identified during the inspection, and the licensee was given the opportunity to submit a plan of correction to address these violations.
Complaint Details
Complaint related to discharge allegations received on 2024-07-09; evidence did not support the allegations.
Report Facts
Number of residents present: 3
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 1
Inspection Report
Routine
Deficiencies: 4
Apr 24, 2024
Visit Reason
Routine inspection conducted to assess compliance with regulatory standards at Pivotal Assisted Living LLC.
Findings
The facility was found to have multiple violations including failure to ensure direct care staff had current first aid certification from an approved vendor, failure to properly chart and obtain physician signatures on oral medication orders within 14 days, medication administration outside the facility's standard dosing schedule, and failure to document all medications administered on the medication administration record.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure direct care staff members have a current certification in first aid from an approved vendor. |
| Facility failed to have the oral order charted by the individual who takes the order nor was the oral order reviewed and signed by a physician or other prescriber within 14 days. |
| Medications were administered later than one hour after facility's standard dosing schedule. |
| Facility failed to document on the medication administration record all medications administered to residents, including over-the-counter medications and dietary supplements. |
Report Facts
Number of staff impacted: 4
Medication administration times: 4
Medication late administration time: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Inspector | Current inspector conducting the inspection. |
Inspection Report
Monitoring
Census: 1
Deficiencies: 0
Mar 7, 2024
Visit Reason
The inspection was a monitoring visit to review the facility's compliance with applicable standards and laws, including review of self-reported incidents and resident observation.
Findings
No violations with applicable standards or laws were found during the inspection. The inspection summary will be posted publicly within five business days.
Report Facts
Records reviewed: 2
Interviews conducted: 1
Inspection Report
Original Licensing
Deficiencies: 0
Nov 6, 2023
Visit Reason
The inspection was an initial licensing inspection conducted to review the facility's compliance with regulations and verify physical plant measurements, policies, and staff records.
Findings
The Licensing Inspector completed an announced initial inspection including a walkthrough of the physical plant, verification of window and room measurements, and review of policies, procedures, and staff records. All inspections have been completed with no complaint related issues.
Report Facts
Records reviewed and interviews conducted: 1
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