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: Feb. 20, 2020

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. 22VAC40-80 THE LICENSING PROCESS.

Comments:

An unannounced renewal inspection was conducted on 2/20/20. At the time of entrance, 121 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, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that a medicine cabinet, container, or compartment is used for storage of medications. The storage area shall be locked. Evidence: During the inspection, the third floor medication cart was observed to be unlocked and unattended at approximately 9:00 AM. The second floor medication cart was observed to be unlocked and unattended at approximately 9:13 AM.
Plan of Correction:	The Director of Nursing held an in-Service with all Nurses and Med Techs on 2-21-2020 following the inspection with DSS. The training was on the importance of securing the medication carts when not under sight or supervision. The DON or designee will do weekly rounds for the next 30 days, starting on 2-21-2020 to ensure the carts are locked when not in sight and to be completed by 3-31-2020 and on-going thereafter. The Director of Nursing, Assistant Director of Nursing, and Memory Care Coordinator will continue to check the Medication carts in passing, along with the other mangers, to ensure we continue to be compliant with company policy, pharmacy policy and state standards. The 2nd floor nurse and 3rd floor Med tech were presented with appropriate corrective action measures to ensure compliance moving forward. They are to follow company policy, pharmacy policy, and State Regulation/Standard.
Standard #:	22VAC40-73-680-D
Description:	Based on documentation, the facility failed to ensure that medications are administered in accordance with the physician's instructions. Evidence: Blood glucose monitoring was observed for Resident #10 during the inspection. Resident #10's medication administration record (MAR) was reviewed during the inspection. Resident #10 has her blood sugar (BS) checked two times per day, and the MAR calls for her to receive Novolog units (U) based on a sliding scale. Resident #10's MAR included the following sliding scale for Novolog administration: 2U (BS= 151 - 200), 4U (BS= 201 - 250), 6U (BS= 251 - 300), 8U (BS= 301 - 350), and 10U (BS= 351 - 400). The MAR included the following Novolog administration for Resident #10: 4U (BS= 268) on 2/5/20 at 5 PM 4U (BS= 268) on 2/6/20 at 5 PM 4U (BS= 286) on 2/7/20 at 5 PM 4U (BS= 286) on 2/17/20 at 5 PM Medication administration was observed for Resident #11 during the inspection. Resident #11's MAR indicated that the resident's Memantine was not administered on 2/8/20, as the medicaiton was not in stock.
Plan of Correction:	Resident #10 was to receive Novolog 6 units per the sliding scale, however the resident only received 4 units. Nurses and Med Techs completed an in-Service Training conducted by the Director of Nursing, (Registered Nurse) on 2-21-2020 on the importance of following physician's orders. The Nurse was presented with corrective action measures to ensure compliance with physician orders, company policy, and State Standards are followed. Audit will be completed by the DON, ADON, and MCC daily starting on 2-24-2020 and will end on 3-24-2020.
Standard #:	22VAC40-73-710-B
Description:	Based on observation and documentation, the facility failed to ensure that physical restraints are used as a medical/orthopedic restraint for support, according to a physician's written order and with the written consent of the resident or his legal representative or (ii) in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others. Evidence: A bed rail was observed on the bed of Resident #9, of the special care unit. Resident #9 has an order, dated 12/20/19, for a hospital bed with rails for turning and repositioning. When asked to demonstrate the usage of the bed rail, Resident #9 was not able to independently reposition himself. Resident #9's record contained a serious cognitive impairment form, dated 3/2/17, that stated that the resident is unable to recognize danger or protect his own safety and welfare. The record also contained a Siderail Use Assessment form that was signed by Resident #9's legal representative, but the assessment information was not documented on the form. Facility staff did not report any emergency situations involving Resident #9.
Plan of Correction:	Resident #9 residing in the memory care special unit side rail was removed immediately on 2-20-2020. Initially prescribed by physician for repositioning purposes, a new order was to discontinue side rail and POA was notified. Staff were in-serviced on restraint free policy on 2-21-2020 and 2-24-2020. C.N.A.'s are required to maintain a restraint free community and were re-trained on such devices that are deemed as a restraint to DSS inspectors. An audit was completed on all assistive devices by the Director of Nursing on 2-29-2020. The Community is appealing this violation due to documentation provided by the attending physician, Director of Rehabilitation contracted with the community, and the resident's ability to use for repositioning only.