VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Meadow Glen of Leesburg
315 Dry Mill Road
Leesburg, VA 20175
(703) 737-6149

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: June 11, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/11/20 and concluded on 6/12/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 36. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards of law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff person submits the results of a tuberculosis risk assessment, on or within seven days prior to the first day of work at the facility. Evidence: The record for Staff #1 was reviewed during the inspection. Staff #1's tuberculosis risk assessment, dated 10/8/19, was completed after the staff member's first day of work, 10/4/19.
Plan of Correction:	The staff member started orientation on 10/4/2019 she returned to continue orientation on 10/7/2019 and then again on 10/8/2019 she was sent for her PPD on 10/8/2019 and it was completed that day prior to her being placed on the schedule for training. The business office manager will be responsible to assure all staff have a completed PPD on the first day of orientation.
Standard #:	22VAC40-73-440-D
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument is complete. Evidence: Resident #2's record was reviewed during the inspection. Resident #2's uniform assessment instrument (UAI), dated 1/15/20, did not include information about the type of assistance that the resident needs for: toileting, continence, wheeling, and mobility.
Plan of Correction:	The resident's UAI was completed during his assessment on 1/15/2020 with needs help completed, the UAI failed to have all check marks under the assistance provided. The UAI was updated to be complete on 6/12/2020. The careplan was complete and accurate with all the residents needs. The Resident Care Coordinator and the Executive Director will check the UAI prior to being placed in the chart for accuracy.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications were administered in accordance with the physician's instructions. Evidence: Resident #2's medication administration record (MAR) was reviewed during the inspection. Resident #2's record contained an order for Atenolol, dated 1/21/20. The order calls for Resident #2 to receive the medication daily, and that the medication should be held if Resident #2's heart rate (HR) is less than 60 or the systolic blood pressure (SBP) is less than 110. The medication was documented as being given on 5/19/20, when Resident #2's SBP was 100. The medication was also documented as being given on 5/26/20, when Resident #2's SBP was 108.
Plan of Correction:	The Resident Care Coordinator sent communication to the resident physician to alert them of the medication error on the two dates. A refresher communication was sent to all RMA's and LPN's to carefully acknowledge any parameters of medication administration. QuickMar was set up with an alert to RCC and ED for blood pressure readings out of parameter. The Resident Care Coordinator will review medication administration records once a month to ensure compliance.