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: July 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Documentation was discussed with the provider.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/8/22 (9:05 AM ? 12:35 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/16/22 regarding allegations in the area of Resident Care and Related Services. The evidence gathered during the investigation supported some, but not all of the allegations. Areas of non-compliance: medication administration. No violations were cited in the area of: care planning. Any violations not related to the complaint, but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations:

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 or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Morning medication administration, for Resident #1, was observed during the inspection. Several of Resident #1?s medications were placed in a pill sleeve and the medication packages were returned to the medication cart. Before the medications could be crushed, the licensing inspector asked about Resident #1?s Metoprolol Succinate. The Metoprolol Succinate bottle states that it should not be crushed or chewed. Resident #1?s chart includes an order, dated 6/29/22, that states that the facility may crush chewable medications.
Plan of Correction:	The charge nurses, ADON, and DON will ensure that all medications and treatments are administered or preformed per the physicians? orders or instructions. These are and will continue to be audited on a monthly basis and compared to the Physician order sheets. In this situation, the medication in referenced, the physician?s order indicated that the medication could be crushed, but upon inspection there was a small label on the medication container indicating that ?Do Not Crush?. ADON & DON have reached out to the pharmacy to ensure that the EMR system indicates medications that are not to be crushed to alert the Med Tech?s and/or LPN?s.