VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Braddock Glen
4027 Olley Lane
Fairfax, VA 22032
(703) 425-3535

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: March 13, 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 Background Checks for Assisted Living Facilities Sworn Statement

Comments:

Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: This LI observed residents participating in various activity programs and eating lunch. This LI observed a medication pass and compared physician orders to the medications available to administered to residents. LI reviewed fire inspection report, health inspection report, fire drills, emergency preparedness review with staff, emergency drills, healthcare oversight, medication review, dietary review and resident council minutes. Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings. 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on resident records review and staff interview, the facility staff failed to ensure that medications were administered in accordance with the physician?s or prescriber?s orders. Evidence: Resident E had a prescription dated 11/18/23 for Labetalol HCI oral tablet 200mg, take every 24 hours as needed if SBP greater than 180 or DBP less than 100. LI compared physician/prescriber?s order sheets with the medications available in the medication cart for Resident E and the medication card for Labetalol HCI oral tablet 200mg did not contain any tablets to dispense during the LI?s inspection on 3/14/2024. Staff A stated that the medication was not available and would need to be reordered.
Plan of Correction:	A.) With respect to the specific resident/situation cited: Res E did not experience any negative outcomes and the medication, Labetalol is available for administration. B.) 4/10/2024-4/11/2024 - With respect to how the facility will identify residents/situations with the potential for the identified concerns: Wellness Nurse (WN) and Medication Care Manager (MCM) conducted eMAR to medication cart audit to confirm medications were available per physician's order. Refresher training with MCM and WN was conducted by Executive Director (ED) regarding procedures to follow in order to administer medications in accordance with the physician's order. When MCM is unable to locate a medication, the MCM is to check the cart to verify it has not been stored correctly, to report to the Resident Care Director (RCD) and notify the physician. If medication is unable to be located the medication will be reordered. C.) 4/11/2024 - With respect to what systematic measures have been put into place to address the stated concern: The RCD or designee will continue to conduct eMAR to medication cart audits weekly for 3 months to confirm that medications are available and administered per physician's order. D.) 4/16/2024 - With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training in order to correct any deficient practices. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.