VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Friendship Salem Terrace
1851 Harrogate Drive
Salem, VA 24153
(540) 444-0343

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Feb. 24, 2025

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 GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 02/24/2025 from 08:15 AM to 05:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on record review and staff interview, the facility failed to ensure that its medication management plan included methods to prevent the use of outdated medications, specifically regarding insulin. EVIDENCE: 1. On the date of inspection, LI reviewed the facility?s plan for medication management from its policy and procedure manual, last updated 08/18/2023. The review did not result in locating the methods that the facility uses to prevent the use of outdated insulin. 2. An interview with staff 4 and staff 5 was unsuccessful at locating this information elsewhere.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission ofthis Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on record review andstaff interview;the facility failed to have, keep current, and implement a written plan for medication managementto include methods to prevent the use of outdated, damaged, or contaminated medications. All medication administration staff will be in-serviced on the following standard to include the revision of our medication management plan and the updated processes to which wewill ensure all medications are labeled and dated properly after opening.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and staff interview, the facility failed to ensure that medications are administered according to physician?s or other prescriber?s orders. EVIDENCE: 1. On the date of inspection, the record for resident 6 contained physician?s orders for NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML ? ?Inject 20 unit subcutaneously one time a day for DM2 hold for BG <115?, effective 05/01/2024 for 0800 administration. 2. The February 2025 medication administration record (MAR) for resident 6 indicates that on 02/24/2025 at 0800, the blood sugar reading for resident 6 was 103; however, that MAR indicates that the resident was administered the 20 units from NOVOLOG FLEXPEN 100 UNIT/ML at the morning (0800) medication pass even though the reading was below 115 and should have been held, per the physician?s order. 3. An interview with staff 5 was unsuccessful in locating any signed documentation where those orders were changed.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on record review and staff interview, Medications shall be administered in accordance with the physician's or other prescriber?s instructions, and consistent with the standard of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. All medication administration staff will be in-serviced on the following standard to include the proper process per our medication management plan. Parameter driven documentation hold will be initiated with our EMR to ensure accurate documentation and 100% audit of all residents with parameters due to insulin use will be completed daily over the next 30 days.
Standard #:	22VAC40-73-680-E
Description:	Based on record review and observation, the facility failed to ensure that medical procedures ordered by a physician or other prescriber shall be provided according to his instructions and documented. EVIDENCE: 1. On the date of inspection, the record for resident 6 contained physician?s orders for ACCU-CHECKS AC/HS ? DM ?before meals and at bedtime for monitoring related to TYPE 2 DIABETES MELLITUS?, effective 11/17/2022. 2. During LI?s observation of the lunchtime medication pass on the date of inspection, staff 1 performed the ACCU-CHECK procedure on resident 6 at 11:49 AM; however, LI and staff 1 observed that resident 6 had already been eating lunch at that time; therefore, the ACCU-CHECK was not performed before the meal, per the physician?s order.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on record review and staff interview, Medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident's record. All medication administration staff will be in-serviced on the following standard to include the proper process per our medication management plan. An adjustment of an earlier time to the treatment will be in place to prompt the completion prior to meal time. 100% audit of all residents with blood glucose monitoring will be completed daily over the next 30 days.