VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Woodburn
3450 Gallows Road
Annandale, VA 22003
(703) 462-9998

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: July 18, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 7/18/19 Licensing Inspector (LI) conducted unannounced focused monitoring visit to ensure correction of violations cited during 4/23/19 complaint study. LI also conducted a focused inspection in response to facility self-reports. LI reviewed resident records, reviewed medication administration records, observed a medication pass, and interviewed residents. The violation from the previous inspection was not corrected and a repeat violation of Standard 680-D was cited as well as a violation of Standard 660-A-1. The exit interview was held. 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 #:	22VAC40-73-660-A-1
Description:	Based upon observation, the facility failed to ensure that the storage area for medications shall be locked. Evidence: Licensing Inspector (LI) observed Staff #2 applying ointment to a resident in a nearby hallway. The door to the medication room was left unlocked, opened, and unattended and there were other residents directly outside of the open door to the medication room.
Plan of Correction:	The medication technician (MT) who failed to ensure that the storage area for medications was locked was formally counseled on 7/23/19. All MTs will be re-educated on the medication management policy which includes procedures for proper storage at the next MT meeting in August 2019. Moving forward, the Wellness Nurse or Manager on Duty will ensure that these medication rooms are locked and checked during their daily rounds of the community. Date to be Corrected: 8/31/19 and on-going
Standard #:	22VAC40-73-680-D
Description:	Based upon a review of resident records and other documentation, 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 outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1 had physician's orders to receive Gabapentin 300mg two capsules (600mg) one time a day at bedtime. Staff #1 only administered one 300mg capsule of Gabapentin at bedtime on the following dates: June 18th, 19th, 20th, 21st, 24th, 25th, 26th, and 27th of 2019. Resident #1 had a physician's order to receive Alprazolam 0.5mg one tablet three times a day. Resident #1 missed all the scheduled dosages of Alprazolam for the follwing dates: June 24th, June 25th, June 26th, June 27th, and June 28th of 2019. The controlled drug receipt/record/disposition form indicated that on June 23, 2019, Resident #1 had 29 Alprazolam pills left after the 10:00 pm administration. On June 29, 2019, Resident #1 had 28 Alprazolam pills left after the 10:00 am administration according to the documentation.
Plan of Correction:	Intensive Plan of Correction (IPOC) required.