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

Current Inspector: Marshall G Massenberg (703) 431-4247

Inspection Date: Nov. 30, 2021

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.

Technical Assistance:
Documentation was discussed with the provider.

Comments:
An unannounced renewal inspection was conducted on 11/30/21 (9:00 AM - 6:40 PM). At the time of entrance, 51 residents were in care. A meal, 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 #: 22VAC40-73-250-D
Description: Based on record review, the facility failed to ensure that each staff person, on or within seven days prior to the first day of work, submits the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days.
Evidence: The record for Staff #1, hired 9/17/21, was reviewed during the inspection. The record contained the results of a chest x-ray. The chest x-ray results were more than 30 days old, on or within seven days prior to Staff #1?s first day of work at the facility.

Plan of Correction: Review and training of the Virginia Department of Social Services State Regulations regarding the required information on the physical exam was provided to the HR representative and the Resident Services Coordinator on 12/15/2021. The TB risk assessment will be re-submitted to the appropriate provider for review and completion of the form by 1/1/22.

Executive Director, RSC, Administrative Services Coordinator (ASC) and/or designee will conduct an audit of Employee records to ensure compliance. Documentation of current TB screening will be obtained, placed in employee file and included on an internal spreadsheet for continuous review. Human Services representative, RSC and/or designee will conduct random audits of employee TB screenings.

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 from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid.
Evidence: The record for Staff #2, hired 2/5/21, was reviewed during the inspection. The record contained a statement of participation in an internet based activity from the Postgraduate Institute for Medicine for Healthcare CPR/AED and First Aid, dated 2/11/21. The internet based activity did not include a hands-on skills assessment, nor was it a first aid certification from an approved organization.

Plan of Correction: Staff #2 will attend the next CPR First Aid training tentatively scheduled for 1/10/2022 at the community. Executive Director, Administrative Services Coordinator (ASC) and/or designee will conduct an audit of Employee records for compliance.

Documentation of current certification of CPR and/or First Aid will be obtained, placed in employee file and included on internal spreadsheet upon hire. ASC will maintain internal spreadsheet to ensure compliance. CPR and First Aid Training will be scheduled as needed. ASC and/or designee will conduct audits of employee training records on a quarterly basis to ensure compliance.

Standard #: 22VAC40-73-320-A
Description: Based on record review and interview, the facility failed to ensure that each resident has a physical examination by an independent physician, within the 30 days preceding admission. The report or such examination shall be on file at the assisted living facility.
Evidence: The record for Resident #2, admitted 11/11/21, was reviewed during the inspection. The record did not contain Resident #2?s physical examination report. Facility staff confirmed that the report was not present in the file, at the time of the inspection.

Plan of Correction: We will obtain an updated physical for resident # by 1/1/2022. ED/RSC and/or designee will conduct an audit of residents chart for completion and compliance.

The ED, Marketing Director and/or designee will ensure physical examination for new residents will be obtained within 30 days prior to move in. ED, RSC and/or designee will audit the chart, prior to move in day, to ensure compliance

Standard #: 22VAC40-73-440-L
Description: Based on record review and interview, the facility failed to ensure that each resident?s completed uniform assessment instrument (UAI) is maintained in the resident record.
Evidence: The record for Resident #2, admitted 11/11/21, was reviewed during the inspection. The record did not contain Resident #2?s completed UAI. Facility staff confirmed that the UAI was not in the resident record, at the time of the inspection.

Plan of Correction: ED will complete/update UAI for Resident #2 by 1/1/2022, to reflect current needs, and place in Resident's medical record. Executive Director, RSC and/or designee will conduct an audit of Resident records to ensure UAI?s are completed and compliant filed in the resident's chart.

The RSC will complete UAI training and will audit and review UAI?s in residents chart. ED, RSC or designee will conduct quarterly audits of Resident medical records to ensure compliance.

Standard #: 22VAC40-73-450-C
Description: Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) is based upon the uniform assessment instrument (UAI)
Evidence: Resident #4?s ISP, dated 8/31/21, was reviewed during the inspection. Resident #4?s UAI, dated 5/28/21, states that the resident needs only supervision for bathing and toileting and that the resident needs no assistance for walking, stairclimbing, mobility or dressing. Resident #4?s ISP indicates that the resident needs physical assistance for bathing, extensive cueing for dressing, and supervision for transferring and ambulating.

Plan of Correction: ED will update and the comprehensive individualized service plan (ISP) for Residents #4 based on the UAI and place it in their individual medical records. Executive Director, RSC, and/or designee will conduct an audit of Resident records to ensure comprehensive ISP's have been completed.

ED will utilize updated internal audit form and internal report to ensure comprehensive ISP is completed within thirty days after admission and is based on the UAI. ED and RSC will review compliance for resident ISP on a monthly basis.

Standard #: 22VAC40-73-450-D
Description: Based on record review, the facility failed to ensure that hospice services are included on the individualized service plan.
Evidence: Resident #1?s ISP, dated 10/6/21, was not updated to include the hospice services that were ordered for the resident on 10/9/21.

Plan of Correction: ED will update the comprehensive individualized service plan (ISP) for Resident #1. Executive Director, RSC, and/or designee will conduct an audit of Resident records to ensure comprehensive ISP's have been updated and are in compliance.

ED will utilize updated internal audit form and internal report to ensure comprehensive ISP is completed within thirty days after admission updated as needed. ED and RSC will review compliance for resident ISP on a monthly basis.

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 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 the inspection, Resident #7?s morning medication administration was observed. Resident #7?s record contained an order for Atenolol, dated 10/15/20, that calls for her to receive two 25mg tablets of Atenolol once daily. Resident #7 received only one 25mg Atenolol during the medication administration, as there was only one 25mg tablet available.

Plan of Correction: RSC will provide re-training to LPNs and Medication Techs on the timely ordering, reordering and, administration of prescribed medications. RSC and/or designee will conduct weekly 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 the timely 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. RSC, Executive Director or designee will conduct weekly audits of medication administration and MARs to ensure all medications are available and administered as prescribed.

Standard #: 22VAC40-73-680-I
Description: Based on documentation, the facility failed to ensure that the medication administration record (MAR) includes all of the required information.
Evidence: Resident #2?s November MAR was reviewed during the inspection. The MAR did not include documentation about the administration of Resident #2?s Eliquis on 11/24/21 (8 PM administration).

Resident #7?s MAR did not document why her Gabapentin was not given on 11/12/21 (9 AM administration).

Resident #8?s MAR did not include documentation about his house supplement on 11/5/21 (noon administration) or 11/21/21 (5 PM administration).

Plan of Correction: RSC or designee will educate all nurses and MT on the MARs for compliance of documentation and medication administration. The correct procedures regarding documentation of medication administration and information required on the MARs. RSC and/or designee will conduct weekly audits for compliance.

LPN's and MT's will receive medication documentation training at orientation, annually and as needed by the RSC or designee. RSC, Executive Director and/or designee will conduct weekly audits of medication and MARs.

Standard #: 22VAC40-73-680-M
Description: Based on record review and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence: Resident #2?s PRN Lorazepam, ordered 11/11/21, was not present at the time of the medication cart inspection. Facility staff confirmed that the PRN medication was not present.

Plan of Correction: RSC will provide re-training on the timely ordering, reordering and, administration of prescribed medications. RSC and/or designee will conduct weekly audits of the medications and MARs to ensure compliance.

RSC and/or designee will provide training and/or retraining to LPN's and MT's on the timely 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. RSC, Executive Director or designee will conduct weekly audits of medication administration and MAR's to ensure compliance.

Standard #: 22VAC40-73-710-C
Description: Based on record review, the facility failed to ensure that the requirements for restraint usage were met.
Evidence: Side rails were observed on the beds of Residents #3 and #9. Resident #3?s record (3/20/19) and Resident #9?s record (7/12/21) contained assessments of serious cognitive impairment, that stated that each resident has a serious cognitive impairment and that they are unable to recognize danger or protect their own safety and welfare. No orders for the bed rails were observed in the resident records that listed the conditions, circumstances, or duration for their use.

Plan of Correction: Side rails were removed from the bed for resident #3 and #9. The management team will inspect resident rooms to ensure compliance. Executive Director, RSC, RSS, and/or designee will ensure compliance at move in. RSC and/or designee will conduct random audit room rounds to ensure compliance.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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