VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ashby Ponds, Inc.
21160 Maple Branch Terrace
Ashburn, VA 20147
(571) 291-6210

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 11, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 7/11/19Licensing Inspector (LI) conducted unannounced focused monitoring visit to ensure correction of violations cited during 5/13/19 renewal study. LI reviewed resident records, reviewed medication administration records, and observed medication pass. The violation of Standard 680-C from the previous study was found not to have been corrected and a second violation of the standard was cited. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-C
Description:	Based upon a review of medication administration records the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: Resident #1 is scheduled to receive Tylenol Extra Strength 500mg tablet at 6 pm. On 7/3/19 the medication was administered at 8:09 pm; on 7/7/19 the medication was administered at 7:20 pm; on 7/8/19 the medication was administered at 7:54 pm; and on 7/10/19 the medication was administered at 7:49 pm. Resident #2 is scheduled to receive Lexapro 10mg tablet at 6 pm and Topiramate 50mg tablet at 6 pm. On 7/1/19 both medications were administered at 7:27 pm; on 7/3/19 both medications were administered at 8:47 pm; on 7/6/19 both medications were administered at 7:28 pm; on 7/7/19 both medications were administered at 7:46 pm; on 7/8/19 both medications were administered at 8:35 pm; on 7/10/19 both medications were administered at 8:03 pm. Resident #3 is scheduled to receive Acetaminophen 500mg tablet at 8:00 am and a Cranberry 450 mg tablet at 8:00am. On 7/1/19 both medications were administered at 9:59 am. Resident #4 is scheduled to receive Metformin 500mg tablet at 4:30 pm. On 7/1/19 the medication was administered at 6:21 pm. Resident #5 is scheduled to receive Omeprazole 40mg tablet at 9 am, Tramadol 50mg tablet at 9 am, and a Vit D3 2,000 unit capsule at 9 am. On 7/1/19, all three medications were administered at 10:47 am.
Plan of Correction:	1. Provider was notified for late administration of medication for resident #1, #2, #3, #4, and #5. Staff member identified during survey administering medications out of the one hour parameter was re-educated on medication administration policy on 7/12/19. 2. Wellness manager or designee will complete monthly audit of 10 residents for three months beginning 7/30/19, ensuring medications are administered within medication administration policy, and DSS regulations. 3. Wellness Manager or designee will ensure completion of monthly audits described above. All findings outside of policy and regulation will be reported to our monthly QAPI meeting. If further cases are found, QAPI committee will reeducate staff and complete additional audits. 4. Date to be corrected 8/10/19.