VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harper's Station at Gainesville
15951 Loves Mill Lane
Gainesville, VA 20155
(703) 270-0284

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Dec. 6, 2023

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness Additional Requirements for Facilities that Care for Adults with Cognitive Impairments Background Checks for Assisted Living Facilities Sworn Statement

Comments:

Date of Inspection: December 6 & 27, 2023 Type of Inspection: Renewal inspection Census: 61 Number of records reviewed and interviews conducted- 8 records, 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The LI observed residents participating in activity programs and eating lunch. This licensing inspector observed medication administration and compared physician orders to medications available to be administered to residents. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-680-M
Description:	Based on resident record review and observation, it was determined that the facility failed to ensure PRN medications were available to be administered. Evidence: Resident C had the following PRN medications prescribed but were not available in the medication cart to be administered: Acetaminophen, Calcium Carbonate, Isosorbide Mononitrate or Metamucil.
Plan of Correction:	Request refill reports from Pharmacy weekly. Assign a day of the week that the Supervisor will audit the Med Carts. Quarterly Pharmacy Cart Audits. Contact Physician regarding possibility of reducing amount of PRN medications by scheduling doses. In-service regarding ordering medications timely, PRN medications to be available to residents at all times to be performed with all nurses and medication technicians.