VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Annandale)
7104 Braddock Road
Annandale, VA 22003
(703) 256-0882

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: June 4, 2020

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 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.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/4/20 and concluded on 6/9/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 30. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid. Evidence: Documentation from Staff #3's record was reviewed during the inspection. The record contained first aid certification that expired in January 2020. Current first aid certification was not provided for Staff #3, during the inspection.
Plan of Correction:	Staff #3 was asked to provide documentation of current first aid certification and, if unable to provide the requested documentation, to schedule First Aid training as soon as possible. Resources were provided to staff #3 on where to attend first aid training if needed. Executive Director, Resident Services Coordinator (RSC), Administrative Services Coordinator (ASC) and/or designee will conduct an audit of Employee records to identify any additional employees without current certifications in CPR and/or First Aid. CPR and First Aid Training has been scheduled, via ZOOM, at the community on June 26, 2020 for any employee whose certification of CPR and/or First Aid is in danger of expiring before December 30, 2020. Documentation of current certification of CPR and/or First Aid will be placed in employee record and included on internal spreadsheet upon hire and prior to working with Residents. An internal spreadsheet, identifying CPR and First Aid certification expiration dates, will be maintained by the ASC and/or designee and updated to identify those employees in need of recertification. CPR and First Aid Training will be scheduled quarterly or, as needed, to insure all employees maintain current certifications. Regional Human Resources Director and/or Regional Quality Assurance Consultant will conduct random audits of employee training records on a quarterly basis to insure employees are current with CPR and First Aid certifications.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that each resident's physical examination includes all of the required information. Evidence: Resident #1's physical examination form was reviewed during the inspection. The physical examination form, dated 3/21/19, did not include Resident #1's height, weight, blood pressure, and allergic reactions. Resident #2's physical examination form was reviewed during the inspection. The physical examination form, dated 3/9/20, did not include Resident #2's height, weight, and blood pressure. Resident #2's record contained the results of a tuberculosis risk assessment, dated 1/24/20. Resident #2 was admitted to the facility on 3/10/20. The tuberculosis risk assessment was more than 30 days old, at the time of Resident #2's admission.
Plan of Correction:	The Weight and Vital Summary, containing Admission Vital Signs was located for Resident #2, printed and attached to the original physical examination form. Upon retrieval of Resident #1's thinned file from our company storage facility, we will attach documentation of Admission Vital Signs to that Resident?s physical examination form as well. RSC and/or designee currently conducting an audit of all Resident physical examination forms to identify any missing information and attach Admission Vital Signs documentation if needed. RSC, ED and/or designee will review the physical examination form for each Resident prior to/upon move-in to ensure all required documentation has been completed, accurately and fully, by the individual?s licensed provider. RSC, ED and/or designee will review the physical examination form for each Resident prior to/upon move-in to insure all required documentation has been completed, accurately and fully, by the individual's licensed provider. A qualified healthcare provider will audit Resident records to ensure all Resident physical examination forms have been completed accurately during the healthcare oversight and, as needed.
Standard #:	22VAC40-73-550-G
Description:	Based on documentation and interview, the facility failed to ensure that the written acknowledgment, of a review of the rights and responsibilities of residents in assisted living, is filed in the resident record. Evidence: The most recent written acknowledgment, of resident's rights, was requested for Resident #1 and Resident #3. The written acknowledgments were not provided, during the inspection. Facility staff reported that the written acknowledgments were not able to be located.
Plan of Correction:	Written copies of Resident's Rights, along with, documentation of written acknowledgement, was provided to legal representatives/responsible individuals on June 05, 2020. Documentation of written acknowledgement has been filed in the Residents? respective records. ASC and/or designee will conduct audits of all Resident records to insure written acknowledgement of Residents Rights is filed appropriately. ASC and/or designee will utilize company program and/or Outlook Calendar to schedule Annual Resident Rights review to insure required acknowledgement documentation is obtained and filed within the specified time requirement. RSC, Executive Director and/or designee will conduct impromptu audits of Resident records for required documentation. A qualified healthcare provider will audit Resident records to insure all required documentation is filed and maintained appropriately during the healthcare oversight and, as needed.
Standard #:	22VAC40-73-650-E
Description:	Based on record review and interview, the facility failed to ensure that physician's orders are contained in the resident record. Evidence: The MAR, for Resident #1, documented that the resident received alendronate sodium and AZO Cranberry Gummies during the month of May. Resident #1's physician's orders for alendronate sodium and AZO Cranberry Gummies were not provided, during the inspection. Facility staff reported that the orders were at the facility's storage facility.
Plan of Correction:	The physician's orders noted, that were thinned/removed from the Resident's record and sent to the company storage facility, have been requested and are in the process of being returned to the community. Upon arrival, the records will be maintained onsite and available for the required time period, as specified by DSS Regulations. RSC and/or designee will audit all Resident records to insure all required orders/documentation are maintained onsite and available for the required time period, as specified by DSS Regulations. RSC and/or designee will provide training/retraining to LPN's regarding the thinning of Resident records, as well as, the DSS Regulations for maintaining the documentation onsite. Training will be conducted and reviewed by the RSC and/or designee upon orientation, annually and, as needed. RSC, Executive Director or designee will conduct impromptu audits of Resident records for required documentation. A qualified healthcare provider will review Resident records for appropriate documentation during the healthcare oversight and, as needed.
Standard #:	22VAC40-73-680-D
Description:	Based on documentation, the facility failed to ensure that medications are administered in accordance with the physician's instructions. Evidence: Resident #2's record contained an order for Miralax, dated 5/5/20. The medication administration record (MAR) indicated that Resident #2 did not begin receiving Miralax until 5/11/20. Resident #2's record contained an order for Trazadone, dated 5/27/20. The MAR indicated that Resident #2 was not given Trazadone during the month of May. Resident #2's MAR indicated that Medroxyprogesterone was ordered for the resident on 3/19/20. Resident #2's record contained an order to discontinue the Medroxyprogesterone, dated 5/8/20. The MAR indicated that Resident #2 was not given Medroxyprogesterone from 5/1/20 - 5/7/20.
Plan of Correction:	The nurses, responsible for administering the medications noted, were re-trained on the process of timely ordering, reordering and, administration of prescribed medications. The training included the process/policy of obtaining medications from our preferred pharmacy when medications are not received from the family/responsible party in a timely fashion if they are providing the medications. New Resident Services Coordinator (RSC), hired on May 26, 2020, and/or designee will conduct impromptu audits of the medications and Medication Administration Record?s (MAR) to ensure all medications are available and administered as prescribed. RSC and/or designee will provide training/retraining to all LPN's and MT's on the timely ordering/reordering and administration of prescribed medications. The training will include the process/policy of obtaining medications from our preferred pharmacy when medications are not received from the family/responsible party in a timely fashion if they are providing the medications. This training will be conducted and reviewed by the RSC and/or designee at orientation, annually and, as needed. RSC, Executive Director or designee will conduct impromptu audits of medication administration and MAR's to insure all medications are available and administered as prescribed. A qualified healthcare provider will audit MAR's to insure all prescribed medications are available and administered during the healthcare oversight and, as needed.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview, the facility failed to obtain a criminal history record report within 30 days of hiring an employee. Evidence: The records of new staff members (#s 1, 4, 5, 6, and 7) contained criminal record checks that were provided by a private company. The records of Staff #8 and #9, hired 7/16/19, contained criminal background checks from the Department of State Police that were dated 1/28/20. The records of these employees, did not contain a criminal history record report from the Department of State Police, by the 30th day of employment for each employee.
Plan of Correction:	Criminal History Record Reports, from the Department of State Police, have been obtained for identified employees and filed in their records. New Administrative Services Coordinator (ASC), hired May 18, 2020, and/or designee is conducting an audit of new employees, hired during the time we did not have a full time ASC (January 4, 2020 to May 18, 2020), to ensure criminal history record reports have been obtained and filed in the employee records. ASC and/or designee will utilize company documentation checklist to ensure criminal history record report has been obtained, accurate and in compliance with DSS and company regulations and policies. ASC, Executive Director and/or designee will review each new employee record within 30 days to insure criminal history record report has been obtained, is accurate and in compliance with DSS and company regulations and policies. The Regional Human Resources Director and/or Regional Quality Assurance Consultant will conduct random audits of employee records on a quarterly basis to ensure compliance.