VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Evergreen Assisted Living Community
1437 Peter's Creek Road, NW
Roanoke, VA 24017
(540) 526-8022

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Nov. 20, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 11/20/2020 and concluded on 12/21/2020. A self-reported incident was received by the department regarding allegations in the areas of medication administration. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-670-1
Description:	670 Based on record review, the facility failed to ensure that each staff person who administers medication shall be authorized by ? 54.1-3408 of the Virginia Drug Control Act. EVIDENCE: 1. On 11/20/2020, the facility made a self-report that staff 1, who was not authorized to administer medications in an assisted living facility, had administered resident 1 her prescribed PRN dose of Acetaminophen 325 mg medication during the previous night as was requested for pain. 2. The record for resident 1 did contain a valid physician?s order for two tablets of Acetaminophen 325 mg by mouth every four hours, as needed for pain. 3. Staff 2 indicated that staff 1 has not obtained licensure by the Commonwealth of Virginia to administer medications and is not registered with the Virginia Board of Nursing as a medication aide.
Plan of Correction:	1. The Administrator shall ensure that no staff member who is not a Registered Medication Aide administer medications to residents. 2. The Administrator shall ensure that all medications given to resident has a valid physician order. 3. The Administrator shall ensure that only Registered Medication Aides administer medications to residents at the facility.