VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Linden House
1250 Branchlands Drive
Charlottesville, VA 22901
(434) 973-0311

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: May 25, 2022 and June 9, 2022

Complaint Related: Yes

Comments:

Type of inspection: Complaint The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint report was received by VDSS Division of Licensing on 05/25/2022 regarding allegations in the areas of medication administration. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: medication administration. A violation notice was issued. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on the review of facility records the facility failed to ensure that at the time that the medication is administered, the facility documented on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements. Evidence: Resident #1 Facility staff did not document on the facility MAR charting for January 2022 whether the 1/2 tab 50mg (25mg) of the medication Tramadol was administered to the resident on 01/30/2022 at 12:00.M.
Plan of Correction:	FACILITY'S RESPONSE: "Linden House acknowledges that the MAR for January 30, 2022 MAR is incorrect. It is unable to revise the MAR to reflect that one dose of the medication was not administered on that date. The Director of Health and Memory Care manager will continue to monitor medication exceptions and re-educate the RMAs and Licensed Nurses on proper documentation."