VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Culpepper Garden III INC
4439 N. Pershing Drive
Arlington, VA 22203
(703) 528-0162

Current Inspector: Alexandra Roberts

Inspection Date: Aug. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Technical Assistance:

Facility's Infection Control Plan currently under review for updates per 22 VAC 40-73-100.

Comments:

An unannounced renewal study was conducted from 8:45a.m. - 4:05p.m. on 8/27/2019. At the time of entrance 69 residents were in care. The sample size consisted of ten resident records and five staff records. Staff and four residents were interviewed. Resident, staff and pet records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 5/31/2019 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including exercise, brain games and ping pong toss. Medication administration was observed with two stafff and medication carts observed for PRN medications. Building and Grounds observed. Violation and risk ratings reviewed and exit interview held. Inspection documentation sent at a later date. 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) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-B
Description:	Based on record review and observation, facility failed to ensure that the licensee, administrator, or his designee shall develop a comprehensive Individualized Service Plan (ISP) to meet the resident's service needs and the plan shall support the principles of individuality and shall include other formal and informal supports. Evidence: During observation of medication administration, Licensing Inspector (LI) observed communication difficulties between Staff #1 and Resident #2 and Staff #1 and Resident #4; LI observed Resident #2 and Resident #4 speaking Spanish and not speaking English and the language preference and other formal and informal supports.was not indicated on Resident #2's most recent ISP dated 6/4/2019 and was not indicated on Resident #4"s most recent ISP dated 4/9/2019).
Plan of Correction:	ISP?s were updated to include ?language barrier?. Residents noted, speak Spanish, understand English, but communication by resident is mainly in Spanish (limited English). Will maintain all ISP?s with residents who have a language barrier/ communication difficulties. DON and ADM responsible for initiating and follow up on ISP?s
Standard #:	22VAC40-73-680-H
Description:	Based on observation and interview, facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents. Evidence: During medication administration, Licensing Inspector (LI) observed Staff #1 document the administration of Hydrocortisone Cream 1% (behind ears), Petrolatum Jelly (vaginal area), and Triamcino Acet 0.1% Cream (perineal area and under breasts) to Resident #1 and did not observe the administration of the medications and Staff #1 stated that the medications had been administered to the resident in her room earlier during morning care. LI observed Staff #1 walking in the hall and Staff #1 stated she was on her way to the bathroom and LI asked Staff #1 for a review of the PRNs on the medication cart; upon arrival to the cart, LI observed Staff #1 document administration of medication on the electronic medication administration record (MAR) and did not observe the administration of the medication.
Plan of Correction:	All treatments done at 7am will be scheduled as such and documented at time done. Inservice was held on 8/27/19, 8/28/19, 8/29/19 regarding the giving of medications/treatments. It is mandatory that they are signed out at the time med given or treatment done and not to be given and then signed out later even though done or within 5 minutes of being given (not acceptable). The med cart and/or the lap top with the packaged/labeled medication will accompany the medication aide when distributing any medications to the residents, no matter their location in the facility. DON/ADON responsible for ongoing scheduled training.
Standard #:	22VAC40-73-690-B
Description:	Based on observation and interview, facility failed to ensure that for each resident assessed for assisted living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, shall perform a review every six months of all the medications of the resident. Evidence: Staff #2 was observed administering medication (Amlodipine 5mg, Metoprolol 50mg, Aspirin 81mg, Atorvastatin 80mg, Bupropion 150mg, and Clopidogrel 75mg) to Resident #5 at 9:34 a.m. in her room and Resident #5 has an order to self-administer over-the-counter medications medications also noted on her most recent UAI dated 5/1/2019; Medications (Aspirin 81mg, Acetaminophen 500mg, Motrin 200mg, Tussin DM, Naproxen Sodium 220mg, Stool softener 100mg and Omeprazole 20mg) were observed on Resident #5's bedroom nightstand and in bathroom cabinet and most recent physician order dated 5/30/2019 and physician's most recent current medication review dated 4/11/2019 did not include orders for Acetaminophen 500mg, Motrin 200mg, Tussin DM, Naproxen Sodium 220mg, Stool softener 100mg and Omeprazole 20mg and orders for those medications were not found in Resident #5's record.
Plan of Correction:	9/27/19 All apartments checked to make sure no medications were in apartments that do not self administer. 9/28/19 For the residents who self administer, all meds in their possession were reviewed and currently in the process of obtaining orders for all unlisted meds. Some of these residents as (resident #5) gave us permission to go ahead and administer all meds, so those residents have no meds in their apartments. The residents were instructed that the facility MUST have on file an order for all meds that they take DON/ADON must be kept informed of any new prescriptions or changes in their current medications. Notes are currently being posted quarterly regarding this information. Every 6 months when the self administer review is done and as needed, any new meds will be updated and expired meds thrown out. DON/ADON responsible for oversight.