VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heatherwood Independent and Assisted Living
9642 Burke Lake Road
Burke, VA 22015
(703) 425-1698

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Oct. 5, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated complaint inspection was initiated on 10/5/21 and concluded on 10/15/21. A complaint was received by the department regarding allegations in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector conducted an on-site observation at the facility on 10/5/21. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber'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 #1's August 2021 Medication Administration Record (MAR) was reviewed during the inspection. Resident #1's Senna-Docusate Sodium tablet, ordered 7/30/20, was not documented as administered on 8/20/21 or 8/27/21. The MAR referenced a progress note, which stated that the medication was on hold, as the facility was waiting for the delivery of the medication.
Plan of Correction:	Complete an in-house count of 100% of resident?s medications to ensure availability to administer as physician?s or other prescriber?s instructions. All LPNs and Medications Tech will be trained on medication administration and proper documentation. Wellness Director or designee will review all documented medications holds daily for accuracy. To be completed on or before 10/30/21
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that the MAR includes all of the required information. Evidence: Resident #2's August 2021 MAR was reviewed during the inspection. The MAR did not include administration information about the application of Resident #2's Lidocaine Patch on 8/30/21. The MAR references a progress note in Resident #2's record, but the note only includes the information from the physician's order for the Lidocaine patch. The progress note does not provide documentation that Resident #2's Lidocaine patch was applied.
Plan of Correction:	Complete an in-house count of 100% of resident?s medication administration records to ensure accuracy to reflect physician?s or other prescriber?s instructions and orders. All LPNs and Medications Tech will be trained on medication administration and proper documentation. Wellness Director or designee will review medication administration records to ensure it includes all required information. To be completed on or before 10/30/21