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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: Feb. 21, 2023

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
An unannounced complaint inspection was conducted on 2/21/23 in response to a complaint received by the licensing office on 2/10/23 regarding Resident Care and Related Services, and Administration and Administrative Services. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) 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
Complaint related: Yes
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 outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence: The morning medication administration was observed, for Resident #1, during the inspection. Resident #1's medication administration record (MAR) called for her to receive 100mcg of Vitamin B12 and 25mcg of Vitamin D daily. Resident #1 was given 1000mcg of Vitamin B12 and 50mcg of Vitamin D, during the observed medication administration.

Novolog administration was observed for Resident #2, during the inspection. Resident #2 was going to be administered 28 units of Novolog, before being stopped by the resident's family member. Resident #2's MAR called for her to receive Novolog on a sliding scale. Resident #2's blood sugar was recorded to be 196. The sliding scale indicated that she is supposed to receive 16 units of Novolog, when her blood sugar is between 151 and 200. A review of Resident #2's MAR, states that the resident's Novolog was not administered on 2/2/23 at 6:30 AM (BS: 144) or 2/4/23 at 6:30 AM (BS: 134). The MAR stated that no coverage was required for those administration times on 2/2/23 and 2/4/23.

Resident #3's February MAR was reviewed, during the inspection. Resident #3's MAR states that she was administered Metoprolol on 2/11/23 (BP: 108/72) and 2/14/23 (BP: 101/73). Resident #3's MAR states that her Metoprolol should be held for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 60.

Plan of Correction: Facility obtained updated order for resident medication. All Registered Medication Aides will complete Registered Medication Continuing Education Course. Clinical administration will conduct routine, unannounced medication administration audits for monitoring and observation.

Standard #: 22VAC40-73-680-I
Complaint related: Yes
Description: Based on documentation, the facility failed to ensure that the medication administration record (MAR) includes all of the required information.
Evidence: Resident #2?s February MAR was observed, during the inspection. Resident #2?s MAR did not include information about the administration of her Novolog on 2/5/23 (6:30 AM administration).

Plan of Correction: Facility will ensure all MARs include all required information. Nursing Administration to monitor MARs weekly in conjunction with QA meetings to ensure compliance. Wellness director will conduct monthly audits for 90 days.

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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