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: April 26, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated complaint inspection was initiated on 4/26/21 and concluded on 6/30/21. A complaint was received by the department regarding allegations in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector conducted an on-site observation at the facility on 6/23/21. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure that the comprehensive individualized service plan is completed within 30 days after admission. Evidence: Resident #1 was admitted to the facility on 3/14/20. The initial service plan, dated 3/14/20, was included in the resident record, but a comprehensive service plan was not completed. The facility administrator confirmed that a comprehensive individualized service plan was not in Resident #1's record.
Plan of Correction:	Deficiencies were based on a complaint received by the DSS licensing office, in April 2021, in the area of Resident Care and Related Services from March and April of 2020. The investigation was initiated by the DSS Licensing Inspector on 4/26/2021 and concluded on 6/30/21. New Resident Services Coordinator (RSC), hired on May 26, 2020, initiated an audit of all Individualized Service Plans (ISP) to ensure accuracy. RSC, Executive Director or designee will conduct impromptu audits to ensure the ISP of each Resident is accurate. An internal tracking system for ISP's will be reviewed weekly to ensure compliance with the state standards. A qualified healthcare provider conducting healthcare oversight will audit ISPs for accuracy.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that individualized service plans (ISPs) are reviewed and updated as needed for a change in a resident's condition. Evidence: Resident #1 was admitted to the facility on 3/14/20. Resident #1's initial service plan, dated 3/14/20, was the only service plan included in the resident record. The service plan was not updated to include skilled nursing wound care services, ordered 3/18/20. Wound care notes, from 3/18/20, report that three wounds were treated on Resident #1's feet/legs. The notes also state that services would be provided three times per week, that Resident #1 has a history of disruptive behavior, and she has tendency to remove wound dressings. By 3/27/20, wound care notes reported that five wounds were treated on Resident #1's feet/legs. On 4/27/20, wound care notes reported that five wounds were still being treated on Resident #1's feet/legs, but one wound began to emit an odor and a podiatrist evaluation was requested because a wound was not healing as expected. On 4/28/20, the podiatrist diagnosed Resident #1 with an infection and antibiotics were ordered. On 4/29/20, wound care notes reported that 10 wounds were treated on Resident #1?s feet/legs. On 5/11/20, wound care notes reported 12 wounds were treated on Resident #1?s feet/legs. Wound care notes reported that Resident #1 should keep wound dressings in place, and that facility staff had been notified that Resident #1 should wear non-skid slippers instead of shoes. The notes report that "wearing shoes traumatize they wound additionally, keeps it moist and prevents the healing process" (sic). The service plan states that Resident #1 needs physical assistance for dressing and that she will be dressed appropriately. The service plan did not include the recommendations from the wound care service provider. Resident #1's record contains an order for a wheelchair, dated 4/28/20. A physician's order, dated 5/4/20, calls for Resident #1 to be non-weightbearing while an ulcer is present on her left heel. On 5/6/20, wound care notes reported that Resident #1 was having difficulty ambulating. The service plan was not updated to reflect the changes to Resident #1's ambulation status, as the plan states that Resident #1 ambulates independently and no assistive devices are needed.
Plan of Correction:	Deficiencies were based on a complaint received by the DSS licensing office, in April 2021, in the area of Resident Care and Related Services from March and April of 2020. The investigation was initiated by the DSS Licensing Inspector on 4/26/2021 and concluded on 6/30/2021. New Resident Services Coordinator (RSC), hired on May 26, 2020, initiated an audit of all Individualized Service Plans (ISP) to ensure accuracy. RSC, Executive Director or designee will conduct impromptu audits to ensure the ISP of each Resident is accurate. An internal tracking system for ISP's will be reviewed weekly to ensure compliance with the state standards. RSC, Executive Director or designee will conduct impromptu audits to ensure the ISP of each Resident is accurate. An internal tracking system for ISP's will be reviewed weekly to ensure compliance with the state standards. A qualified healthcare provider conducting healthcare oversight will audit ISP's for accuracy.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that medications are 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: The controlled drug recording form for Resident #1 was observed. The form calls for staff members to document on the form, when controlled medications are administered. Resident #1's Alprazolam Concentrate order for anxiety, dated 3/12/20, called for the resident to receive 0.25ml three times per day. The controlled drug record documented that Resident #1 was given 1ml of Alprazolam on 4/1/20 (9AM administration). No documentation was present, on the controlled drug record, to indicate the administration of Alprazolam on: 4/1/20 (3PM and 9PM administrations), 4/2/20 (9AM, 3PM, and 9PM administrations), 4/3/20 (9AM administration), 4/9/20 (3PM and 9PM administrations), 4/11/20 (9PM administration).
Plan of Correction:	Deficiencies were based on a complaint received by the DSS licensing office, in April 2021, regarding medication administration from March and April 2020. The investigation was initiated by the DSS Licensing Inspector on 4/26/2021 and concluded on 6/30/2021. Upon internal review of the Medication Administration Record (MAR), it appears that the specified order documented on the March MAR had not been transcribed onto the April MAR until April 3, 2020 thereby causing the ordered medication not to be administered. The staff member who administered the 9:00 AM dose of the specified medication on April 1, 2020 has not been employed with the community as of May 15, 2020. New Resident Services Coordinator (RSC), hired on May 26, 2020, initiated an audit of all Resident medical charts. RSC and/or designee will conduct impromptu audits of the medications and MARs to ensure all medications are transcribed, available and administered as prescribed. RSC and/or designee will provide training and/or retraining to LPN's and MT's on the timely transaction, ordering/reordering and administration of prescribed medications. This training will be conducted and reviewed by the RSC and/or designee on orientation, annually and, as needed. In addition, the RSC and/or designee will review all new, discontinued, or medication order changes within 24-48 hours. RSC, Executive Director or designee will conduct impromptu audits of medication administration and MARs to ensure all medications are transcribed, available and administered as prescribed. A qualified healthcare provider will audit MARs to ensure all prescribed medications are transcribed, available and administered during the quarterly healthcare oversight.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on record review, the facility failed to document on the medication administration record (MAR), all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: No information was present on the MAR to document the administration of Resident #1's Risperidone on 4/1/20 (9 AM and noon administrations) or 4/22/20 (noon administration). No information was present on the MAR to document the administration of Resident #1's Aspirin, Citalopram, and Galantamine on 5/4/20 (9AM administration).
Plan of Correction:	Deficiencies were based on a complaint received by the DSS licensing office, in April 2021, regarding medication administration from March, April and, May of 2020. The investigation was initiated by the DSS Licensing Inspector on 4/26/2021 and concluded on 6/30/2021. The staff members who failed to document the administration for the specified medications, have not been employed with the community as of May 15, 2020, February 19, 2021 and, August 2, 2020, respectively. New Resident Services Coordinator (RSC), hired on May 26, 2020, initiated an audit of all Resident medical charts. RSC and/or designee will conduct impromptu audits of the medications and MARs to ensure all medications are available and administered as prescribed. RSC and/or designee will provide training and/or retraining to LPN's and MT's on medication administration/documentation of prescribed medications. This training will be conducted and reviewed by the RSC and/or designee on orientation, annually and, as needed. In addition, the RSC and/or designee will review all MARs regularly for accuracy. A qualified healthcare provider will audit MARs to ensure all prescribed medications are transcribed, available and administered during the quarterly healthcare oversight.