VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tall Oaks Assisted Living
12052 N. Shore Drive
Reston, VA 20190
(703) 834-9800

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Sept. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused-monitoring inspection was conducted on 9/27/19, to follow-up on a high-risk violation that was cited on 7/26/19. Medication administration was observed and documents were reviewed. The violation was discussed and an exit meeting was held. The violation was discussed and an exit meeting 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on observation, the facility failed to ensure that medications are administered in accordance with the physician'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: During the inspection, medication administration for Resident #1 was observed. Facility staff administered one spray of Fluticasone in each of the resident's nostrils. The Fluticasone was then placed back into the box and back into the medication cart. The licensing inspector asked about the resident's Fluticasone, as the medication administration record (MAR) states that the resident should receive two sprays of Fluticasone in each nostril. During the inspection, medication administration for Resident #2 was observed. Several of the resident's medications were crushed and placed into yogurt for administration. The resident record did not contain a physician's order for the resident's medication to be crushed.
Plan of Correction:	The Director of Nursing conducted in-service trainings with all LPNs & Medication Aides on the importance of administering medication as prescribed by the physician and following the standard of practice by the VA board of Nursing. The Memory Care Charge Nurse immediately called the Hospice Home Health nurse to obtain an order for the specific resident to have the medications crushed during administration. Memory Care Charge Nurse completed an audit of all the charts appropriate measures have been put in place for crushing orders.