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: April 21, 2021

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 monitoring inspection was initiated on 4/21/21 and concluded on 4/22/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the census was 37. 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 or law, and violations were documented on the violation notice issued to the facility. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on documentation, the facility failed to ensure that medications are administered in accordance with the physician'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 March MAR (medication administration record) was reviewed during the inspection. Resident #1's record contained an order for Olmesartan Medoxomil 20mg, dated 12/12/20, that called for the resident to receive one-half tablet (10mg) daily. The order stated that the medication is to be held, if Resident #1's blood pressure is less than 100/60. The MAR indicated that Resident #1 was administered Olmesartan Medoxomil on 3/2/21 when the resident's blood pressure was 124/52, and on 3/9/21 when the resident's blood pressure was 140/47.
Plan of Correction:	The physician for that resident was notified that the medication was given out of specified parameters. The RCC initiated with the pharmacy a request for in-person training for all licensed personnel to review the importance of following physician orders. The RCC and ED reviewed with the specific staff member the error. The RCC and ED will continue to monitor all medication orders with parameters to ensure that medication is administered according to physician orders.