VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Journeys Crossing
102 N. Stuart Avenue
Elkton, VA 22827
(540) 298-0054

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Oct. 4, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A self-reported incident was received by VDSS Division of Licensing on 09/21/2022 regarding allegations in the area(s) of: Resident Care. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Rhonda Whitmer Licensing Inspector at (540 292-5932 or by email at rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on document review and an interview, the facility failed to ensure 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: 1. Based on communication from the facility via email on 09/21/2022, the ?Incident Reporting to Licensing Office Form? indicates resident 1 did not receive 2mg of Warfarin that was ordered for daily administration effective 09/08/2022. 2. The report indicates medication was not administered to resident 1 on 09/15/2022; 09/17/2022; 09/18/2022 and 09/20/2022. The report indicates 1mg of Warfarin was administered to resident 1 on 09/16/2022 and 09/19/2022 when 2mg was to be administered. 3. Submitted documentation from the facility via email on 10/04/2022 indicates resident 1?s INR was 2.6 on 09/07/2022 at 3:58pm and 1.2 on 09/21/2022 at 3:40pm. 4. The LI interviewed the administrator on 10/04/2022 who confirmed resident 1 did not receive the correct amount of Warfarin as ordered by the physician. 5. Page 25 #6 A.3 of the current registered medication aide curriculum approved by the Virginia Board of Nursing indicates the right of medication administration as the ?right dose.?
Plan of Correction:	Facility administrator will ensure Registered Medication Aides monitor and report any issues with medication administration for residents receiving Warfarin, issues with the pharmacy supplying medication, or entering the information correctly into the MAR.