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: Feb. 7, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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 63.2 General Provisions. 63.2 Protection of adults and reporting.

Technical Assistance:

Please advise Licensing Inspector when room and water temperature fluctuations are resolved by facility maintenance to address on-going residents' complaints.

Comments:

Licensing Inspectors (LIs) conducted unannounced complaint investigation on 1/07/2020 regarding alleged abuse and neglect, resident care, and resident council follow-up notification. LIs reviewed six resident records and other documentation. LIs interviewed nine residents and three staff including the Director of Nursing (DON). While a preponderance of evidence gathered during the investigation did not support all of the allegations included in the complaint, the complaint is deemed valid as violations related to Standards 22VAC40-73-(2)-70-A, 22VAC40-73-(6)-450-H and 22VAC40-73-(7)-830-E were cited and documentation retained in record. Exit interview conducted on 01/07/2020 and the violations and risk ratings reviewed with DON and visiting Administrator. 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on documentation, record review and interview, each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: Progress notes in Resident #7's record document history of falls and documentation includes 1/30/20 bruise buttock; 1/24/20 agitation with staff and broken toilet; 1/21/2020 old bruise back and small cut head; 1/26/2020 bruise and abrasion breast; 11/25/2019 complaint of pain breast; 11/19/2019 agitation toward staff; 10/28/2019 bruise medial thigh; 10/20/2019 scratch arm; 10/19/2019 bruise lower lip; 9/6/2019 bruise thumb; 7/25/2019 bruise upper breasts; 7/25/2019 bruise wrist; 7/24/2019 complaint of pain trunk; 7/17/2019 bruise wrist; and 7/1/2019 bruise at RUA; Resident #7 refused interview with LIs and an incident report from the facility to document the systemic issue related to Resident #7's behaviors and unexplained bruising and the locations of the bruising that was documented in Resident #7 record was not received by the licensing department. Progress notes in Resident #11's record document 1/27/2020 anxiety and aggression toward staff, left hand tear, agitated and verbally aggressive towards staff; 1/24/2019 anxiety; 1/23/2019 agitated, attempted to enter other residents room and scared them with attempts to physically attack them; 1/23/2020 wandering, attempting to enter other resident's apartment without permission, put hands in staff members face, profanities loudly; 1/20/2020 agitated, verbally aggressive toward staff, attempts to hit staff and other residents; 1/20/2020 disruptive behavior, yelling at other resident's and staff, found entering other residents apartments without permission; 12/23/2019 verbally aggressive and make attempts of physical aggression to staff; 12/23/2019 anxiety and verbal and attempts of physical aggression towards staff, agitation and no compliance; 12/9/2019 increased anxiety, physical and verbal aggression toward staff; increased anxiety and aggression toward staff, refused directional interventions; 11/3/2019 drove staff away aggressively; 10/29/2019 attempted to beat a female staff; 10/28/2019 aggressive and combative toward staff, took his belt and started whipping her; 10/26/2019 drove CNA away; 10/25/2019 combative towards staff; 9/2/2019 agitation/anxiety, attempted to hit staff. An incident report from the facility to document the escalating issue related to Resident #11's behaviors towards staff and then also towards residents was not received by Licensing department prior to the notification on 1/21/2020 of facility's plan to discharge Resident #11.
Plan of Correction:	Moving forward, the Executive Director or Wellness Director will report resident behaviors that could potentially negatively affect or threaten the life, health, safety, or welfare of any resident.
Standard #:	22VAC40-73-450-H
Complaint related:	Yes
Description:	Based on record review, observation and interview, facility failed to ensure that the facility shall ensure that the care and services specified in the Individualized Service Plan (ISP) are provided to each resident, except that deviation from the plan shall be documented in writing, including a description of the circumstances, the date it occurred, and the signatures of the parties involved, and the documentation shall be retained in the resident's record. Evidence: Resident #8's most recent ISP dated 4/12/2019 states "CNA, CMA/T, LPN" are responsible to "Offer toileting before and after meals then before and after each activity programs. Resident needs toileting every hour during the day." Other caregivers and family members are not identified on the ISP to assist with this activity of daily living and Licensing Inspector observed family member toileting resident on two occasions without assistance from staff; interview with family and staff state that family member routinely toilets resident without staff assistance during the day; staff state that toileting is also provided by staff "often throughout the day, not just on a schedule"; documentation was not available to indicate that toileting is provided by staff as noted in the ISP and on the frequency as noted in the ISP. .
Plan of Correction:	Wellness Director to update ISP to reflect that family member may assist staff with toileting. Staff will continue to toilet resident when requested. An audit will be completed by the Wellness Director and Assistant Wellness Director to ensure the resident?s ISP and ADL documentation is accurate according to the resident?s needs.
Standard #:	22VAC40-73-830-E
Complaint related:	Yes
Description:	Based on documentation and interview, facility failed to ensure that the facility shall provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns. Evidence: Resident Council meetings occurred on 11/20/19, 12/18/19 and 1/15/20 and written responses to the council prior to the meetings regarding any recommendations made by the council for resolution of problems or concerns were not available.
Plan of Correction:	Written response provided to residents regarding Resident Council Meeting on 1/15/20 via memo sent by Executive Director prior to February?s Resident Council Meeting. Each month, the Executive Director or designee will provide written response to Resident Council regarding recommendations and concerns made by the council.