VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tribute at The Glen
4151 Old Bridge Road
Woodbridge, VA 22192
(571) 402-1870

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Jan. 3, 2024

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: January 3 and 4, 2024 Type of Inspection: Monitoring Inspection Census: 109 Number of records reviewed and interviews conducted- 7 records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents participating in activity programs and eating lunch. Licensing Inspector observed medication administration and compared physician orders to medications available to be administered to the 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 staff interview, it was determined that the facility failed to have available PRN medication ordered by the resident? physician. Evidence: All prescribed PRN medications for Res C were not available in the facility to be administered.
Plan of Correction:	CORRECTION #1 Facility contacted pharmacy. All PRN medications for Res C were ordered and were made available by facility to be administered. DATE January 20, 2024 CORRECTION #2 Facility Resident Services Director (Registered Nurse) conducting in servicing of all Medication Care Partners on processes and protocols to follow when medications are not available for administration, including contacting pharmacy and notifying facility nurses so that appropriate action can be taken to make medications available by facility to be administered. DATE 2/3/2024 CORRECTION #3 Facility Resident Services Director (Registered Nurse) conducting in servicing of all Nurses (LPNs) on processes and protocols to follow when medications are not available for administration, including daily monitoring of medication management dashboard, communicating with Nurse Practitioners/Physicians as may be necessary for further orders, communicating with pharmacy, and notifying Resident Services Director to ensure that all medications are available by facility to be administered. DATE 2/3/2024 CORRECTION #4 Facility Resident Services Director (Registered Nurse) and LPN(s) will conduct a medication audit of all medication carts to ensure that all prescribed medications are available by facility to be administered. DATE 2/3/2024 CORRECTION #5 Facility Resident Services Director (Registered Nurse) will meet with Facility Executive Director (ALFA) at the conclusion of in servicing and medication audit to provide a report on status and to discuss any additional corrective action that may be needed to ensure that all medications are available by facility to be administered. DATE 2/10/2024