VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cobbdale Assisted Living (Fairfax Co)
3503 Burrows Avenue
Fairfax, VA 22030
(571) 414-1850

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Sept. 20, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:06 am on 9/20/2022 and exited the facility at 11:25 am on 9/20/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 8/7/2022 regarding allegations in the area(s) of: resident care and related services. Number of residents present at the facility at the beginning of the inspection: 8 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon a review of records and interviews, the facility failed to ensure that medications shall be 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 Board of Nursing. Evidence: 1. According to the physician?s orders, Resident #1 has an order for Ativan 1mg 1 tablet to be given at bedtime and has an order for Ativan 0.5mg 1 tablet to be given every six hours as needed (prn). 2. According to interdisciplinary progress note, Staff #1 reported to the nurse that Resident #1 was administered ?the wrong dose of Ativan for her prn dose overnight.? 3. The Medication Administration Record documented Resident #1 received as needed (prn) Ativan at approximately 10:34 pm on 9/6/2022. 4. The administrator and director of nursing confirmed through interviews on 9/20/2022 that on 9/6/2022 that Staff #1 administered 1 mg of Ativan as the prn medication instead of the 0.5mg Ativan that is prescribed by the physician.
Plan of Correction:	Director of Nursing will go over the triple check method of medication administration with med tech who made the medication error.