Inspection Reports for Tilden Memory Care
7800 Belvedere Dr, Alexandria, VA 22306, United States, VA, 22306
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Inspection Report
Renewal
Census: 5
Deficiencies: 10
Apr 25, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations related to documentation, staff certifications, emergency preparedness, staffing plans, and resident discharge procedures. The facility was found non-compliant with several regulatory standards and was issued a violation notice with opportunities to submit plans of correction.
Deficiencies (10)
| Description |
|---|
| Facility failed to prepare a statement on the liability insurance form provided by the department. |
| Facility failed to ensure that the disclosure statement was on a form developed by the department. |
| Facility failed to maintain documentation on volunteers. |
| Facility failed to ensure that each direct care staff member maintained current certification in first aid from approved organizations. |
| Facility failed to maintain a written staffing plan specifying the number and type of direct care staff required. |
| Facility failed to maintain a written work schedule including job classifications and indication of who was in charge. |
| Facility failed to provide the resident and legal representative a dated discharge statement signed by the administrator. |
| Facility failed to develop a written emergency preparedness and response plan that included documentation of annual contact with the local emergency coordinator. |
| Facility failed to implement a semiannual review on the emergency preparedness and response plan for all staff, residents, and volunteers. |
| Facility failed to ensure a criminal history record report was accepted only if dated within 90 days prior to employment. |
Report Facts
Number of residents present: 5
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of staff interviews conducted: 3
Staff 2 first aid certification expiration date: 2024.0925
Staff 4 hire date: 2025.0414
Staff 4 criminal history record report date: 2024.1114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Routine
Census: 7
Deficiencies: 3
Apr 24, 2024
Visit Reason
The inspection was a routine regulatory visit to review compliance with applicable standards and laws at Tilden Memory Care & Assisted Living.
Findings
The inspection found non-compliance with several standards including failure to report major incidents within 24 hours, failure to act on medication review recommendations, and failure to ensure annual fire safety inspections were conducted and documented.
Deficiencies (3)
| Description |
|---|
| Facility failed to report major incidents threatening resident safety to the regional licensing office within 24 hours. |
| Facility failed to ensure action was taken and documented in response to medication review recommendations. |
| Facility failed to ensure an annual fire safety inspection was conducted and reports retained for at least two years. |
Report Facts
Residents present: 7
Resident records reviewed: 3
Staff records reviewed: 4
Resident interviews: 1
Staff interviews: 3
Date of wound documentation: Jan 10, 2024
Date of pharmacy reviews: Sep 20, 2023
Date of pharmacy reviews: Mar 13, 2023
Date of pharmacy reviews: Mar 28, 2023
Date of last fire inspection: Nov 4, 2022
Date of new fire inspection: May 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the inspection |
| Staff 2 | Staff interviewed who was unaware of incident reporting requirements | |
| Staff 4 | Staff interviewed who was unaware of incident reporting and medication review response requirements and fire inspection requirements | |
| Administrator | Person who described corrective actions and plans of correction |
Inspection Report
Renewal
Census: 4
Deficiencies: 0
Jun 15, 2023
Visit Reason
An unannounced renewal inspection was conducted to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. Resident and staff records, background checks, medication administration, and resident activities were reviewed and found compliant.
Report Facts
Residents in care: 4
Staff providing care: 2
Resident records reviewed: 2
Staff records reviewed: 2
Individual interviews conducted: 1
Business days for posting summary: 5
Inspection Report
Monitoring
Census: 4
Deficiencies: 3
Mar 27, 2023
Visit Reason
An unannounced mandated monitoring inspection was conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with several standards including staff tuberculosis screening, uniform assessment instrument completion, and timely development of preliminary plans of care. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that each staff person hired had documentation of a current TB screening prior to hire. |
| Facility failed to ensure that all residents and applicants were assessed face to face using the uniform assessment instrument, specifically missing assessment of mobility and eating/feeding needs. |
| Facility failed to develop a preliminary plan of care on or within seven days prior to admission to address basic resident needs; plan of care was developed one day late. |
Report Facts
Residents in care during inspection: 4
Staff providing care during inspection: 2
Staff hire date missing TB screening: 1
Resident UAI date: Mar 12, 2023
Resident admission date: Jan 1, 2023
Plan of care completion date: Jan 2, 2023
Inspection Report
Original Licensing
Deficiencies: 0
Nov 18, 2022
Visit Reason
The Licensing Inspector conducted an announced initial inspection to verify compliance with state regulations including physical plant conditions, policies, procedures, and background checks.
Findings
No violations were cited during the inspection. The inspector verified window and room measurements, inspected first aid kits, reviewed policies and procedures, and tested the call bell system. All required background checks were received and reviewed.
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