VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pacifica Senior Living Sterling
46555 Harry Byrd Highway
Sterling, VA 20164
(703) 896-9590

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Feb. 24, 2023

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 9:50 am on 2/24/2023 and exited at 12:45 pm on 2/24/2023. 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 1/25/2023 regarding allegations in the area(s) of resident care. Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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 #:	22VAC40-73-660-A
Description:	Based upon interview with staff, the facility failed to ensure that Scheduled II drugs and any other drugs subject to abuse must be kept in a separate locked storage compartment (e.g., a locked cabinet within a locked storage area or a locked container within a locked cabinet or cart). Evidence: 1.During an interview with staff on 2/24/2023, it was revealed that Staff #2 found one bottle of Gabapentin and three bottles of Alprazolam in an unlocked filing cabinet, in the unlocked office of the Resident Services Director.
Plan of Correction:	Daily medication room audits will be conducted by MT (med tech) on duty. Weekly medication room and medication cart audits will be conducted by Resident Services Director (RSD). Weekly medication cart audit conducted by MT on duty. Pharmacy to continue quarterly medication carts and room audits. Signature of completion initiated in-service on the following: narcotic storage and narcotic destruction
Standard #:	22VAC40-73-680-D
Description:	Based upon a review of records, the facility failed to ensure that medication shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards or practice outlines in the current medication aide curriculum approved by the Board of Nursing. Evidence: 1. According to the physician?s orders, Resident #1 is to receive two 300 milligram (mg) capsules of Gabapentin three times a day (approximately 9am, 2pm, and 9pm). 2. According to the Individual Controlled Substance Record, Resident #1 was not administered the scheduled dosages of Gabapentin for the following dates and times: 1/15/2023---approximately 9pm 1/16/2023?approximately 9am 1/16/2023?approximately 2pm 1/16/2023?approximately 9pm. 1/17/2023?approximately 9am 3. According to the Medication Administration Record (MAR) for January 2023, the exception for the Gabapentin not being administered at approximately 9pm on 1/15/2023, approximately 9am on 1/16/2023, approximately 2pm on 1/16/2023, and approximately 9am on 1/17/2023. was documented as ?awaiting medication from pharmacy/family.? 4. According to the delivery manifest of receipt of prescription medications, 90 capsules of Gabapentin for Resident #1 was documented as being received on 12/31/2022 at approximately 9:57 am by the Resident Services Director. 5. According to the incident report submitted to the licensing inspector on 1/25/2023, after searching the medication room and medication carts for the Gabapentin, Resident #1?s Gabapentin (90 capsules) were found in an unlocked filing cabinet, in the unlocked office of the Resident Services Director on 1/17/2023.
Plan of Correction:	Resident Services Director (RSD) to conduct staff in-service on the following: --Five rights of medication management --Medication pass observation of all medication techs. RSD to conduct training on delivery manifest.
Standard #:	22VAC40-73-680-H
Description:	Based on a review of documents, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents. Evidence: 1. According to physician?s orders, Resident #2 has prn (as needed) order for Alprazolam 0.5mg 1.5 tablets as needed. 2. According to a note entered on 1/8/2023 at approximately 8:03 am on the MAR for January 2023 for Resident #2, Alprazolam (prn) was requested at approximately 9pm on 1/7/2023 but was entered on the MAR as being administered on 1/8/2023 at approximately 8:03 am. 3. According to the Individual Controlled Substance record, Alprazolam (prn) was documented as being administered on 1/7/2023 at 9 pm and was signed off by two staff person who worked on different shifts.
Plan of Correction:	Resident Services Director (RSD) to conduct in-service on the following: --Med pass documentation Medication Administration Record (MAR) and Treatment Administration Record (TAR) records will be reviewed twice daily (beginning of day shift and end of evening shift) for omissions and/or errors.