VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mary Marshall Assisted Living Residence
2000 5th Street, South
Arlington, VA 22204
(571) 527-5002

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: March 13, 2023

Complaint Related: Yes

Areas Reviewed:

Resident Care and Related Services Complaint Investigation

Comments:

Date of Inspection: March 23, 2023 Type of Inspection: Complaint inspection Standards Investigated: As stated above Complaint was determined valid If you have any questions, please do not hesitate to contact me at (540) 680-9469 or sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection, you can find the information on the internet: www.dss.virginia.gov The Administrator and the Licensing Inspector discussed the risk assessment ratings for the violations for this inspection.

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record review and staff interview, it was determined that medications for Res C and D were not administered in accordance with the physician's orders. Evidence: The Medication Administration Record (MAR) for Res C indicated that Bupropion HCI ER tablet was not administered to the resident on January 16th and 17th, 2023. The MAR for Res D indicated that Magnesium Oxide tablet was not administered on January 2, 3, 5, 7, 9, 11, 12, 17, 18, 19, 22, 25, 26 and 27, 2023.
Plan of Correction:	1. Staff education on medication ordering, including when to re-order, how to follow-up, charting, interaction with pharmacy, and writing incident reports. 2. Phone conference with Pharmacy reps to resolve issues, including designated person at pharmacy for problem solving, use of back-up pharmacy, notification process for urgent medications that need to be delivered. 3. Allow Pharmacy vendor to access Point Click Care (PCC) to improve monitoring of medications ordered and those due for delivery. 4. Shift reports run by LPN to include missed medications not available, with steps taken to correct any concerns that day.