VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Fair Oaks)
12469 Route 50
Fairfax, VA 22033
(703) 383-0060

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Oct. 23, 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 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.

Comments:

An unannounced renewal inspection was conducted on 10/23/19 (8:00 AM - 6:30 PM). At the time of entrance, 51 residents were in care. Meals, medication administration and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observation and interview, the facility failed to implement the infection control program that addresses the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. Evidence: Resident #1 has a sliding scale for the administration of Novolog. Facility staff was observed using Resident #9's glucometer in order to measure Resident #1's blood sugar. Facility staff reported that Resident #1 did not have any more blood sugar test strips remaining, and that was the reason why Resident #9's glucometer was used. The glucometer was not cleaned after Resident #1's blood sugar was measured.
Plan of Correction:	RSC obtained more test strips and will create par levels for test strips and monitoring weekly for the need to order more test strips. Policy and procedure will be added to the infection control plan in regards to Glucometer usage and cleaning. All newly hired LPNs and med Techs will be in serviced by the RSC or designee to the glucometer usage and clean procedures.
Standard #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure that a medicine cabinet, container, or compartment is used for storage of medications. The storage area shall be locked. Evidence: The medication cart, on the Cloverdale neighborhood, was observed to be unlocked and unattended. The keys for the cart, were left inside the cart's lock. Resident #1's Novolog was left unattended on the medication cart, prior to the observed medication administration.
Plan of Correction:	Staff member who left the med cart unlocked has been counseled. All LPNs and Med Tech in serviced by the RSC or designee on the med plan in regards to requirement to keep med cart locked at all times and no medications left out on top of cart. RSC or designee will in service nursing staff every six months on the med plan.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions. Evidence: The morning medication administration, for Resident #3, was observed during the inspection. Six pills were placed in the resident's pill cup and the medication packages were returned to the medication cart. Resident #3's medication administration record (MAR) calls for the resident to receive seven pills during the morning medication administration. Metoprolol was not included in the resident's pill cup.
Plan of Correction:	Staff member counseled on the proper procedure to pass medications. RSC or designee will in service all nursing staff on the med pass procedure as part of the med plan review every 6 months. RSC or designee will conduct med pass observations on med techs and LPNs periodically to ensure compliance.
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 #1's PRN Miralax and Tussin DM Syrup were not present, at the time of the medication cart inspection. Facility staff confirmed that the medications were unable to be located. Resident #3's PRN Tussin DM Syrup was not present, at the time of the medication cart inspection. Facility staff confirmed that the medication was unable to be located.
Plan of Correction:	RSC or designee will audit all resident PRN medication to ensure medications are available in the cart. RSC or designee will request a D/C order on any prn medications that have not been used in the last 60 days. RSC or designee will audit carts weekly to ensure PRN medications are available.