VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Silverado Alexandria
2807 King Street
Alexandria, VA 22302
(703) 215-9110

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Aug. 31, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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

Technical Assistance:

Documentation was discussed with the provider.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/31/23 (8:50 AM - 4:45 PM) Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 10 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activities The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-660-B
Description:	Based on documentation and observation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs indicate that they are capable of self-administering medication. Evidence: Neosporin + Pain Relief was observed in the bathroom shelf of Resident #4. Resident #4's record contained an order, dated 2/9/22, for Diclofenac gel (DX: Pain). Resident #4's UAI, updated 7/21/23, states that she needs her medication to be administered by professional nursing staff.
Plan of Correction:	Specific resident/situation cited: Resident experienced no negative outcome due to Neosporin with Pain Relief being present in bathroom. Measures to address the concern and how it will be monitored: The Director of Health Services (DHS) or designee will conduct weekly resident room audits for 100% of community for one month to ensure all medications are stored properly. During and at the conclusion of the three months, the DHS and Administrator or their designees, will re-evaluate and initiate necessary action or extend the review period. The Administrator or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that PRN medications are available and properly stored at the facility. Evidence: Resident #6's PRN Loperamide (ordered 3/18/22) and PRN Acetaminophen (ordered 12/2/21) were not present during the medication cart inspection. Facility staff confirmed that the PRN medications were not present, at the time of the medication cart inspection.
Plan of Correction:	Specific resident/situation cited: Resident experienced no negative outcomes from the lack of PRN medication present in medication cart as resident did not require them. Medication orders were discontinued at time of inspection due to not being administered in over 30 days. Measures to address the concern and how it will be monitored: Director of Health Services (DHS) or designee will re-educate LPNs to monitor the availability of PRN medications for the residents per physician orders. DHS or designee will educate LPNs to work with physicians to discontinue any unnecessary medication orders (PRN medications that residents are not requiring for 30 days or more). The DHS or designee will conduct monthly audits of 100% of the medication carts and PRN orders to verify frequency of use of PRN medication and availability. During and at the conclusion of the three months, the DHS and Administrator, or their designees, will re-evaluate and initiate necessary action or extend the review period. The Administrator or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.