VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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: Dec. 28, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/28/23 (8:00 AM - 5:15 PM) Number of residents present at the facility at the beginning of the inspection: 149 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 10 Number of interviews conducted with residents: Three Number of interviews conducted with staff: Three Observations by licensing inspector: Meals, medication administration, activities The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 record review, the facility failed to ensure that 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: Resident #9's December MAR (medication administration record) was reviewed during the inspection. The MAR indicates that Resident #9's Metoprolol Succinate ER should be held when the resident's SBP (systolic blood pressure) is less than 120. The MAR states that Resident #9 was administered Metoprolol on 12/1/23 when the resident's blood pressure was 111/59. The MAR also states that Resident #9 was administered Mtetoprolol on 12/9/23, when the resident's blood pressure was 113/63.
Plan of Correction:	Clinical Services will conduct mandatory re-training for nurses and Registered Medication Aides regarding medication administration/medication management plan. Two clinical team members will verify parameters for all blood pressures prior to medication administration. Clinical administration will conduct routine, unannounced medication administration audits for monitoring and observation.
Standard #:	22VAC40-73-680-M
Description:	Based on record review and observation, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: PRN Aleve, ordered 3/24/22 for Resident #7, was not present during the medication cart inspection. Facility staff confirmed that Resident #7's PRN Aleve was not present, at the time of the medication cart inspection. PRN Acetaminophen, ordered 2/20/19 for Resident #9, was expired at the time of the medication cart inspection. Resident #9's Acetaminophen package expired on 11/30/23. Resident #9's PRN Afrin sinus solution, ordered 5/10/21, was not present during the medication cart inspection. Facility staff confirmed that no additional PRN Acetaminophen was present for Resident #9, and that the resident's Afrin sinus solution was not present at the time of the medication cart inspection. PRN Clindamycin, ordered 10/25/22 for Resident #11, was expired at the time of the medication cart inspection. The medication package indicated that the medication expired in July 2023. Facility staff confirmed that no additional Clindamycin was present for Resident #11, at the time of the medication cart inspection.
Plan of Correction:	PRN medications were immediately ordered and available the same day. All PRN medications will be reviewed on a weekly basis to ensure availability.