VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Auburn Hill at Swift Creek
5800 Harbour Lane
Midlothian, VA 23112
(804) 456-4455

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Aug. 21, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-21-2023 1:01 ? 1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6/14/2023 and 6/21/2023 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 76 Number of resident records reviewed: 2 An exit meeting will be conducted to review the inspection findings. 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview with staff, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. An incident report received 6-11-2023 documented Resident #1 was administered a medication that was not prescribed to the resident. The final updated report on 6-14-2023 documented the medications were Carvedilol 12.5 mg and Tylenol 650mg and that neither were prescribed to Resident #1. 2. Additionally, an incident report received 6-22-2023 documented Resident #2 was administered a medication that was prescribed to the resident with a later effective ?start? date. The initial/final report dated 6-21-2023 documented Amoxicillin 500 mg three times per day for seven days, and Chlorhexidine 0.12% rinse twice daily was due to start 8-02-2023. 3. The facility?s Medication Administration plan documented, ?No medication shall be started without an order by the physician? (dated 07-06-2020). 4. The ?Five Rights of Medication Administration? provided by the facility documented ?the second, and also very obvious, right is to ensure that the medication is being administered to the right patient.? (dated 2016). 5. Staff #1 confirmed during interview the aforementioned medications were administered and were not in accordance with physician?s instructions for Resident #1 or Resident #2.
Plan of Correction:	Resident number one on 06/11/2203 MD and legal representative notified. Resident was monitored with no negative outcome. Internal medication incident was completed. Resident number two on 06/14/2203 MD and legal representative notified. Resident was monitored with no negative outcome. Internal medication incident was completed. Reduction to RMA and LPN?s on communities medication management plan(?five rights of medication administration?) to be completed by 11/30/2023. Director of Health and Wellness, Director of Memory Care, or designee audit medication pass observation weekly x30 days. Reeducation as needed.