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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: March 14, 2023

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 GENERAL PROVISIONS
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments:
An unannounced complaint inspection was conducted in response to complaints received by the licensing office on 1/30/23 and 3/6/23; regarding General Procedures and Resident Care and Related Services. Building and grounds were inspected, medication administration was observed, and facility documents were reviewed. Violations were discussed and an exit meeting was held.

The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #: 22VAC40-73-450-E
Complaint related: Yes
Description: Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the administrator or designee and by the resident or his/her legal guardian.
Evidence: ISPs were observed for Residents #1-4. Resident #1?s ISP, dated 5/25/22, was not signed the resident or her legal representative. Resident #2?s ISP, dated 3/4/22, was not signed by the resident or her legal representative. Resident #3?s ISP, dated 4/11/22, was not signed by the resident or his legal representative. Resident #4?s ISP, dated 5/6/22, was not signed by the resident or her legal representative.

Plan of Correction: ED and/or designee will send out Resident ISP?s for Residents #1, #2, #3 and #4 by 04/05/2023 by certified mail to request signature of RP. The ISP?s were not completed by current Executive Director. The Executive Director has initiated an audit of all Resident?s Individualized Service Plans (ISP) to ensure ISPs? are signed the ones not signed and due for review ED and/or designee will send out to RP certified mail requesting signature and all initiated by current Executive Director and/or designee will be reviewed and signed by both Executive Director and/ or designee and RP, all updates completed by 04/20/2023.

Standard #: 22VAC40-73-460-H
Complaint related: Yes
Description: Based on record review, the facility failed to ensure that personal assistance and care is provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: Bathing ? at least twice a week, but more often if needed or desired.
Evidence: The facility?s February shower logs were observed during the inspection. Resident #3?s ISP, dated 4/11/22, states that he needs staff assistance for bathing. Resident #3?s only documented shower, on the February shower log, was completed on 2/23/23.


Resident #5?s ISP states that she needs staff assistance for bathing. The only information about Resident #5, on the February shower log, was a shower refusal on 2/8/23.

Resident #6?s ISP states that she needs staff assistance for bathing. Resident #6?s only documented shower, on the February shower log, was completed on 2/6/23.

Plan of Correction: RCS was unable to correct Resident #3 and Resident #4 shower log as the observation occurred in real time during the survey. RSC/and ED will conduct an audit of all Resident records to ensure all residents have shower logs and audited daily to ensure that all showers are being completed and if not RSC will notify RP and physician of any complications or refusal of this task.

Standard #: 22VAC40-73-680-D
Complaint related: Yes
Description: Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician?s instructions.
Evidence: The morning medication administration, for Resident #1, was observed during the inspection. Resident #1?s medications were removed from their medication packages, and placed in a pill sleeve to be crushed. Before the medications could be crushed, the licensing inspector inquired about Resident #1?s Ferrous Sulfate. Resident #1?s MAR (medication administration record) stated that the Ferrous Sulfate should not be crushed or chewed.

Plan of Correction: Nurse was able to correct Resident #1 medication administration while the observation occurred in real time during the survey. Resident Services Coordinator (RSC) and/or designee provided training and will review MARS and 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.

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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