VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Poet's Walk of Leesburg
102 Desmond Plaza
Leesburg, VA 20175
(571) 224-9516

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: March 23, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 12 noon on 3/23/2023 and exited at 3:30 pm on 3/23/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/22/2023 regarding allegations in the area(s) of staffing and supervision and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: Additional Comments/Discussion: 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 of non-compliance with standard(s) or law were resident care and related services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Jamie Eddy), Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based upon a review of record and interview with a collateral contact, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: According to the January 2023 Medication Administration Record (MAR) for Resident #1 medications to be administered at approximately 7:30am, 9:00am, and 10:00 am on 1/28/2023 were not administered.
Plan of Correction:	An audit was performed for Resident #1 MAR (Medication Administration Record) on 3/23/2023. Agency staff in building at the time failed to sign the MAR as medication given. Agency exited the building and current staff have been mentored on the importance of signing medications at the time they are given in the MAR. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) with outgoing staff will conduct daily checks to ensure all medications have been administered and documented. DON and ADON will complete weekly checks.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that the Medication Administration Record (MAR) shall include: any medication errors or omissions. Evidence: The January 2023 MAR for Resident #4 does not document the administration of or omission of Diltiazem HCl on 1/28/2023 at approximately 10 am. The MAR does indicate that other medications to be administered at 10 am on 1/28/2023 were given to Resident #4.
Plan of Correction:	Agency staff in building at the time failed to sign the MAR as medication given. Agency exited the building and current staff have been mentored on the importance of signing medications at the time they are given in the MAR. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) with outgoing staff will conduct daily checks to ensure all medications have been administered and documented. DON and ADON will complete weekly checks.