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Paul Spring Independent and Assisted Living Community
7116 Fort Hunt Road
Alexandria, VA 22307
(703) 768-0234

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Nov. 25, 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
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Article 1
Subjectivity
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:
Documentation was discussed with the provider.

Comments:
An unannounced renewal inspection was conducted on 11/25/19 (8:00 AM - 7:30 PM). At the time of entrance, 139 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were 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, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:
Standard #: 22VAC40-73-100-A
Description: Based on observation, the facility failed to implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations.
Evidence: The morning medication administration, for Resident #11, was observed during the inspection. Resident #12's glucometer was used to measure Resident #11's blood sugar. The facility's infection control plan states that each resident shall have his/her own glucometer. No procedures, for the sharing of glucometers, was located in the infection control plan.

Plan of Correction: Each resident receiving assistance with blood sugar monitoring currently has their own glucometer, no sharing of glucometers is permitted per the facility's policy. Resident #11?s glucometer was immediately located and properly labeled for use. Regular checks of glucometers will be conducted by the Wellness Director or Assistant Wellness Director during medication chart checks.

Standard #: 22VAC40-73-250-D
Description: Based on record review, the facility failed to ensure that each staff member submits the results of a risk assessment, documenting the absence of tuberculosis in a communicable form. The risk assessment shall be provided on or within seven days prior to the first day of work and shall be no older than 30 days.
Evidence: The chest x-ray for Staff #1, hired 5/16/19, was completed in June 2017. The x-ray was more than 30 days old, when Staff #1 was hired.

Plan of Correction: Staff #1 will receive a new tuberculosis risk assessment. Human Resources Manager will ensure that all staff will have a documented tuberculosis risk assessment on file within seven days of first day of work and shall not be more than 30 days old, even if the staff member has a current chest x-ray that is negative.

Standard #: 22VAC40-73-320-B
Description: Based on record review, the facility failed to ensure that each resident receives a risk assessment for tuberculosis annually.
Evidence: The most recent tuberculosis risk assessment, in the record for Resident #7, was dated 10/31/18. The risk assessment was more than a year old, at the time of the inspection.

Plan of Correction: Resident #7?s primary care physician was immediately notified of the need for an annual tuberculosis risk assessment. The Wellness Director will use our electronic medical records system to track and document annual tuberculosis risk assessments for all residents. A monthly review of this documentation will be conducted by the Wellness Director.

Standard #: 22VAC40-73-530-C
Description: Based on observation and interview, the facility failed to ensure that freedom of movement is provided for the residents to their personal spaces. The facility shall not lock residents out of or inside their rooms.
Evidence: Resident #13 was observed in a common area of the special care unit. The resident's door was locked. Facility staff reported that Resident #13 is not capable of operating a door lock.

Plan of Correction: The locking door hardware will be removed allowing Resident #13 to freely access resident?s personal spaces. A review of all residents? personal spaces will be conducted By the Director of Environmental Services to ensure residents are able to freely access their space. All locking hardware will be removed if
applicable. Director of Environmental Services will routinely inspect secure care unit to ensure residents have freedom of movement.

Standard #: 22VAC40-73-640-A
Description: Based on observation and documentation, the facility failed to implement the medication management plan.
Evidence: A medication tablet was able to be retrieved from the flap of the medication cart's sharps container. The facility's medication management plan calls for medications to be mixed with an undesirable substance before being placed in an impermeable, non-descript container and placed into the trash.

Plan of Correction: All medication aides and nurses will be trained on medication tablet disposal per our Medication Management Plan and consulting pharmacy policies. Wellness Director will ensure disposal of unused, unneeded or expired medications will be mixed in an undesirable substance prior to storing in a non-descript container or securely stored in a sealed container prior to turning them over to a disposal company.

Standard #: 22VAC40-73-680-D
Description: Based on observation and documentation, 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: The morning medication administration, for Resident #3, was observed during the inspection. Facility staff reported that the resident's lisinopril would be held due to the medication's parameters. The medication administration record (MAR) for Resident #3 indicates that the medication was also held on: 11/2, 11/3, 11/10, 11/11, 11/16, 11/17, 11/18. Resident #3's lisinopril order, dated 4/9/19, did not contain administration parameters.

Plan of Correction: The original medication order had a goal for the resident #3?s blood pressure and a clarification order was received on date of inspection from Resident #3?s primary care physician. All nurses and medication aides will be trained on medication parameters. The Wellness Director will monitor medication administration records for any medications that are held and verify if parameters to hold were met.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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