VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Aarondale Retirement & Assisted Living Community
6929 Matthew Place
Springfield, VA 22151
(703) 813-1800

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Oct. 10, 2019 and Oct. 11, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 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.

Technical Assistance:

For verification, please ensure that all required documentation includes written description with original names, signatures and dates without the use of correction tape or products. Please ensure a correct understanding by providers who complete the ambulatory and nonambulatory status of residents.

Comments:

An unannounced renewal study was conducted from 8:30 a.m. - 5:30 p.m. on 10/10/2019 and from 8:00 a.m.m - 4:00 pm on 10/11/2019. At the time of entrance 70 residents were in care. The sample size consisted of ten resident records and five staff records. Six residents, two family member, staff and ancillary staff were interviewed. No volunteers and no pets reported at facility. Resident and staff, records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 10/24/2018 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including Bingo, Chronicles, Live music entertainment and singing, and outdoor music with conversation. Medication administration was observed with one staff and PRN medications observed. Building and Grounds observed. Violation and risk ratings reviewed during exit interview with Administrator and Wellness Director. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record review, facility failed to ensure that prior to placing a resident with a serious cognitive impairment in a safe, secure environment, the facility shall obtain the written approval of the resident, guardian or legal representative or relative. Evidence: Resident # 8 was admitted into the facility's safe, secure environment on 7/24/2019 and the written approval order of priority form in record was signed by the power of attorney and dated on 7/28/2019, and the appropriateness form in record was signed by designee and dated on 7/28/2019.
Plan of Correction:	Facility will implement a pre-admission checklist to ensure that all proper paperwork is obtained prior to the admission of a resident into the facility?s safe, secure, environment. Wellness Director will complete admission paperwork audit prior to resident?s physical move into the facility to ensure all documents are signed and dated accordingly.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, interview and documentation review, 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 Virginia Board of Nursing. Evidence: During observation of medication administration on 10/10/19, at 8:50 a.m. Staff #1 poured Resident #1's zinc oxide into a cup and did not administer when resident refused and then stored the cup of medication in the medication cart drawer and staff interview stated plans to administer later. At 9:05 a.m. Staff #1 poured Resident #2's medications (Torsemide, Metoprolol, Prednisone, Senna, Aspirin) into a cup and stored the cup of medication in drawer of medication cart and medication was observed administered to resident after resident finished breakfast at 9:26 a.m.; Resident #2's nystop was observed documented on MAR by Staff#1 and administration of medication was not observed; compression garment and splint was observed documented on MAR by Staff #1 and administration was not observed at 9:26 a.m. and prescribed items were not observed on Resident #2 at the time of medication administration and at 2:00 p.m. observation in salon. At 9:12 a.m. Staff #1 placed Resident #3's Dorzolamide on the medication cart and walked away from the medication cart and room for supplies and Resident #3's Senna-Docusate and Multivitamin were observed in the medication cart without resident name or pharmacy label.
Plan of Correction:	Staff #1 was re-educated by Wellness Director and Assistant Wellness Director on proper policies and procedures on medication administration. Staff #1 attended continuing education Med Tech class. Additionally, The Regional Director of Clinical Services will conduct a mandatory training for all nurses and med techs regarding best practices for medication administration. The Wellness Director and Assistant Wellness Director will conduct routine unannounced medication pass audits for monitoring and observation. Wellness Director and Assistant Wellness Director will also conduct routine cart audits to ensure proper labeling for all medications.