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: Sept. 26, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 9/26/2019 Licensing Inspector (LI) conducted unannounced focused monitoring visit to ensure correction of a high-risk violation cited during 8/27/2019 renewal study. Observed medication administration and interviewed resident and staff. Previous violation was repeated and violation cited. Exit interview held. 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 #:	22VAC40-73-680-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 observation of morning medication administration to Resident #1 in the dining room, Licensing Inspector (LI) observed Staff #1 document the administration of the medication Biofreeze and did not observe the administration of the Biofreeze to Resident #1. Resident and Staff interviews stated that the oral medications are usually administered during the meal at the dining room table and then the Biofreeze is administered outside of the wellness office after breakfast is finished.
Plan of Correction:	All medication aides were given hands on in service and explained the importance of documenting the medication when given, may it be a treatment or scheduled medication. Ongoing monthly monitoring and documentation for oversight of medication aides continues to make sure that proper procedures are being followed.