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: Dec. 1, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/1/22 (8:30 AM - 7:10 PM) Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure that each resident is assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, before they are admitted into the safe, secure environment. Evidence: A completed Assessment of Serious Cognitive Impairment form was not included in Resident #1?s record. Resident #1?s record contained the first page of the assessment. The second page of the assessment was not present, at the time of the inspection. Resident #5?s Assessment of Serious Cognitive Impairment form, dated 6/8/22, states that the resident does not have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and that the resident is able to recognize danger or protect her own safety and welfare.
Plan of Correction:	Unable to make changes to original documentation for Resident #1 and #5. Physician assessed and completed new Assessment of Serious Cognitive Impairment for Residents #1 and #5 on December 14, 2022. ED and/or designee will conduct an audit of all Resident records to ensure an Assessment of Serious Cognitive Impairment has been completed for each Resident and filed in their respective medical records.
Standard #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that the administrator or designee performs a review of continued appropriateness, six months after a resident is placed in the safe, secure environment and annually thereafter. Evidence: Resident #1 was admitted to the facility in July 2021. No review of continued appropriateness was observed in the resident record. Resident #2 was admitted to the facility in February 2022. No review of continued appropriateness was observed in the resident record. Resident #3?s last review of continued appropriateness was completed on 2/1/21. Resident #3?s last review of continued appropriateness was more than a year old, at the time of the inspection. Resident #4 was admitted to the facility in April 2022. No review of continued appropriateness was observed in the resident record. Resident #6?s last review of continued appropriateness was completed on 8/1/21. Resident #6?s last review of continued appropriateness was more than a year old, at the time of the inspection.
Plan of Correction:	ED completed a review of continued appropriateness for Residents #1, #2, #3, #4 and, #6 and, placed in Residents individual medical records on December 14, 2022. ED and/or designee will conduct an audit of all Resident records to ensure a review of continued appropriateness has been completed for each Resident and filed in their respective medical records.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment documenting that the individual is free 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. Evidence: The most recent tuberculosis risk assessments, included in the staff records of Staff #1 (8/19/19) and Staff #2 (9/13/21), were more than a year old at the time of the inspection. No documentation was provided, during the inspection, to confirm that more recent tuberculosis risk assessments were completed for Staff #1 or Staff #2.
Plan of Correction:	Primary care physician completed a tuberculosis risk assessment for Staff #1 and #2 on December 14, 2022. Primary care physician will complete a tuberculosis risk assessment for all staff annually and, provide documentation per state regulations. Facility will maintain required documentation in individual staff records per state regulations.
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: No documentation was provided, during the inspection, to confirm that Staff #4 has a current certification in first aid. Staff #4?s record contained documentation of CPR certification, but not first aid.
Plan of Correction:	First Aid and CPR training, as approved by state regulations, has been scheduled for staff #4 on 01/11/2023. Executive Director initiated an audit of all Staff records to identify any additional staff members requiring first aid and/or CRP training to maintain compliance with state regulations. Any staff members identified will be scheduled to attend the First Aid and CPR training on 01/26/2023.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that a risk assessment for tuberculosis is completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident #7?s most recent tuberculosis risk assessment, included in the resident record, was completed on 8/10/21. No additional documentation was provided, during the inspection, to confirm that Resident #7 received a tuberculosis risk assessment within the past year.
Plan of Correction:	Primary care physician completed a tuberculosis risk assessment for Resident #7 on December 14, 2022. While primary care physician was onsite, all residents were assessed and tuberculosis risk assessments completed and filed in their respective records.
Standard #:	22VAC40-73-440-L
Description:	Based on record review, the facility failed to ensure that the completed UAI is maintained in the resident record. Evidence: The following UAIs were the most recent UAIs in the records of: Resident #1 (7/13/21), Resident #3 (5/24/21), Resident #6 (7/16/21), and Resident #7 (8/17/21).
Plan of Correction:	ED completed/updated UAI for Residents #1, #3, #6 and #7 on 12/15/2022 to reflect current needs and placed in Resident?s medical records. Executive Director, RSC and/or designee will conduct an audit of Resident records to ensure UAI?s are complete, current, and accurate based on their individual needs.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure that ISPs are reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: The following ISPs were the most recent ISPs in the records of: Resident #1 (10/6/21), Resident #3 (5/27/21), Resident #6 (7/19/21), and Resident #7 (9/21/21).
Plan of Correction:	ED and/or designee will update ISP?s for Residents #1, #3, #6 and #7 by 12/21/2022 to reflect current needs and placed in Resident?s medical records. Executive Director has initiated an audit of all Resident?s Individualized Service Plans (ISP) to ensure ISPs? are complete, current, and accurate based on their individual needs and will have all updates completed by 01/31/2023.
Standard #:	22VAC40-73-490-A
Description:	Based on documentation, the facility failed to ensure that a licensed health care professional provides health care oversight at least every three months. If the facility employs a licensed health care professional who is on site on a full-time basis, the health care oversight shall be provided at least every six months. Evidence: No documentation of health care over sight was provided, during the inspection.
Plan of Correction:	Regional Quality Assurance Consultant (QAC) will conduct a semi-annual health care oversight. Documentation of semi-annual health care oversight will be completed and maintained in facility as required by state regulations.
Standard #:	22VAC40-73-650-C
Description:	Based on record review, the facility failed to ensure that physician?s phone orders are reviewed and signed by the physician within 14 days. Evidence: Paxlovid was ordered for Residents #2, #4, and #7 in October 2022. The Paxlovid orders were not signed, at the time of the inspection.
Plan of Correction:	Primary care physician signed off on Paxlovid orders for Residents #2, #4 and #7 on December 14, 2022. ED and/or designee will conduct an audit of all Resident telephone records, beginning with all orders received on December 1, 2022, and forward, to ensure all telephone orders have been signed off on by the Residents physician.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and documentation, the facility failed to ensure that a medicine cabinet is used for the storage of medications and that the storage area is locked. Evidence: Resident #2?s insulin administration (10 AM) was observed during the inspection. Resident #2?s insulin was removed from the medication cart, and the staff member went to administer the medication to Resident #2, who was sitting in the living room. When the staff member went to administer the medication, the medication cart was left unlocked. Shortly after 8:40 AM, chest rub and medicated powder were observed to be unlocked and unattended in the bathroom of Resident #4. Bacitracin ointment, triple antibiotic ointment, and corn/callus remover were observed to be unlocked and unattended in the bathroom of Resident #5.
Plan of Correction:	Unable to correct violation pertaining to Med Cart as it occurred during time of survey. All Medicated treatments found in resident rooms, #4 and #5, during survey-inspection was removed immediately on day of survey. All resident rooms were inspected by Quality Assurance Consultant (RN), on December 14, 2022 to ensure there were no medicated treatments in resident rooms. Resident Services Coordinator (RSC) and/or designee will provide training and/or retraining to all employees regarding correct and safe storage of medicated treatments. This training will be conducted and reviewed by the RSC and/or designee on orientation, annually and, as needed. Resident Services Coordinator (RSC) and/or designee will conduct random audits of resident rooms to ensure compliance with state regulations.
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 and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Morning medication administration for Resident #3 was observed during the inspection. Several of Resident #3?s medications were placed in a pouch to be crushed. Before the medications were crushed, the licensing inspector inquired about Resident #3?s crushable medication. Resident #3?s Desvenlafaxine was among the medications that were going to be crushed. Medication documentation for Desvenlafaxine states that the medication should not be chewed or crushed. Resident #2?s November MAR (medication administration record) was reviewed during the inspection. Resident #2 has her blood sugar checked daily, and the MAR calls for her to receive Insulin units based on a sliding scale. Resident #2?s MAR included the following sliding scale for insulin administration: 1U (BS: 150-200), 2U (BS: 201-250), 4U (BS: 251-300), 6U (BS: 301-350), 8U (BS: 351-400), 8U + Call MD (BS > 401) The MAR included the following administration of Insulin for Resident #2: 0U (BS: 189) on 11/2/22 (7 AM administration) 0U (BS: 166) on 11/4/22 (7 AM administration) 0U (BS: 181) on 11/5/22 (7 AM administration) 5U (BS: 252) on 11/8/22 (7 AM administration) 0U (BS: 165) on 11/18/22 (7 AM administration 0U (BS: 157) on 11/19/22 (7 AM administration 0U (BS: 155) on 11/22/22 (7 AM administration) 2U (BS: 254) on 11/25/22 (7 AM administration) 0U (BS: 226) on 11/27/22 (7 AM administration) 0U (BS: 183) on 11/28/22 (7 AM administration)
Plan of Correction:	Unable to correct Resident #3 as the observation occurred in real time during the survey. Unable to correct Resident #2 administration of insulin as identified documentation was dated November 2022. Resident Services Coordinator (RSC) and/or designee will provide training and/or retraining to LPN?s and Medication Aides (MA?s) correct administration of prescribed medications This training will be conducted and reviewed by the RSC and/or designee on orientation, annually and, as needed.
Standard #:	22VAC40-73-680-I
Description:	Based on documentation, the facility failed to ensure that the MAR (medication administration record) is includes all of the required information. Evidence: Resident #1?s MARs were reviewed during the inspection. Resident #1?s MAR did not include documentation about the administration of his Metformin on 11/30/22 at 9 AM. Resident #3?s MARs were reviewed during the inspection. No documentation was included on Resident #3?s MAR for the administration of Acetaminophen on 12/1/22 at 6 AM.
Plan of Correction:	Unable to make changes on November 30, 2022 MAR for Resident #1 and the December 1, 2022 MAR for Resident #3. Resident Services Coordinator (RSC) and/or designee will provide training and/or retraining to LPN?s and Medication Aides (MA?s) correct administration of prescribed medications This training will be conducted and reviewed by the RSC and/or designee on orientation, annually and, as needed. Resident Services Coordinator (RSC) and/or designee will conduct random audits of MAR?s to ensure compliance with state regulations.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials are kept in a locked area. Evidence: Polident cleaning tabs were observed to be unlocked and unattended in the rooms of Residents #5 and #9. Plaster of Paris dry mix was observed to be unlocked and unattended in the activity studio.
Plan of Correction:	The Polident Cleaning Tabs found in resident rooms, #5 and #9, during survey inspection, were removed immediately on day of survey. The Plaster of Paris dry mix observed in the studio during the inspection was removed immediately on the day of survey as well. All resident rooms and, the studio, were inspected by Quality Assurance Consultant (RN), on December 14, 2022 to ensure there were no cleaning materials or other hazardous materials accessible to residents. Resident Services Coordinator (RSC) and/or designee will provide training and/or retraining to employees regarding correct and safe storage of cleaning supplies and/or hazardous materials. This training will be conducted and reviewed by the RSC and/or designee on orientation, annually and, as needed. Resident Services Coordinator (RSC) and/or designee will conduct random audits of resident rooms and, common areas, to ensure compliance with state regulations.
Standard #:	22VAC40-73-950-E
Description:	Based on documentation, the facility failed to develop and implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. Evidence: No documentation was provided, during the inspection, to confirm that a review of the emergency preparedness and response plan was completed with staff, residents, and volunteers within the past six months.
Plan of Correction:	ED and/or designee will conduct a semi-annual review on the emergency preparedness and response plan for all staff, residents and volunteers and will maintain appropriate documentation.
Standard #:	22VAC40-73-990-C
Description:	Based on documentation, the facility failed to ensure that all staff currently on duty, on each shift, participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: No documentation was provided, during the inspection, to confirm that an exercise in which the procedures for resident emergencies was conducted within the past six months.
Plan of Correction:	ED and/or designee conducted an exercise in which the procedures for resident emergencies were practiced on December 14, 2022 for the staff on duty on the 3:00pm to 11:00pm shift. ED and/or designee will conduct an exercise in which the procedures for resident emergencies all staff on the 7:00am to 3:00pm and, the 11:00pm to 7:00am shifts. Appropriate documentation of resident emergency procedures exercises will be maintained per state regulations.
Standard #:	22VAC40-90-40-B
Description:	Based on documentation and interview, the facility failed to obtain a criminal history record report within 30 days of each employee?s hire date and maintain the report at the facility. Evidence: Criminal history reports were reviewed for all new staff members, hired since the last inspection. The criminal history reports for Staff #4, #5, and #6 were not available for review, during the inspection. Facility staff confirmed that the criminal history reports were not present, at the time of the inspection.
Plan of Correction:	Criminal history reports for Staff #4, #5 and #6 will be obtained by December 21,2022, and placed in their individual files. ED, Administrative Services Coordinator (ASC) and/or designee will conduct an audit of all employee records to ensure employee records include criminal background check documentation. New employee records will be audited by the ED, ASC and/or the ED upon hire and/or within 30 days of hire