VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Aarondale Retirement & Assisted Living Community
6929 Matthew Place
Springfield, VA 22151
(703) 813-1800

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: July 27, 2023 , Aug. 3, 2023 , Aug. 4, 2023 and Sept. 21, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/27/23, 7/31/23, 8/3/23, 8/4/23, 9/21/23. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/26/23 regarding an allegation in the area of: Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of interviews conducted with staff: 14 The evidence gathered during the investigation supported the complaint 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 #:	22VAC40-73-1140-B
Complaint related:	Yes
Description:	Based on record review and documentation, the facility failed to ensure that each direct care staff member attends at least 10 hours of training in cognitive impairment within four months of the starting date of employment in the safe, secure environment. Evidence: Staff #5 was hired on 3/9/23. Documentation indicates that Staff #5 only worked on the facility?s memory care unit. No documentation was provided, during the inspection to indicate that Staff #5 completed 10 hours of training in cognitive impairment within four months of working on the facility?s memory care unit. Staff #5?s training transcript indicates that he completed five hours of training in cognitive impairment, within four months of his starting date of employment in the safe, secure environment.
Plan of Correction:	In respect to the specific resident/situation cited: Staff member #5 terminated. In respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and Executive Director will review training modules to ensure that current staff have completed 10 hours of training in cognitive impairment within four months of working in the facilities memory care unit. With respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services and Executive Director will review training modules to ensure that future staff completes 10 hours of training in cognitive impairment within four months of working in the facilities memory care unit. With respect to how the Plan of Correction will be monitored: Human Resources will review staff records for completion of required training, quarterly.
Standard #:	22VAC40-73-270-1
Complaint related:	Yes
Description:	Based on record review and documentation, the facility failed to ensure that each staff member is trained in dealing with aggressive residents, prior to being involved with their care. Evidence: Staff #5 (hired 3/9/23) completed a statement, dated 7/27/23, indicating that he only worked in the facility?s memory care unit. Resident #1?s progress notes state that she was transferred to the memory care unit on 6/8/23. Resident #1?s ISP, dated 6/8/23, states that she exhibits aggressive, abusive, disruptive, and agitated behavior. Resident #1?s UAI, dated 6/8/23, states that she is abusive/aggressive/disruptive- weekly or more. Staff #5?s statement indicated that he participated in the care for Resident #1 on 7/22/23. No documentation was observed in Staff #5?s record to confirm that he received training in dealing with aggressive residents.
Plan of Correction:	In respect to the specific resident/situation cited: Immediate action involved in-servicing staff on abuse, neglect, misappropriation and resident rights. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical Services and Executive Director will review training modules to ensure that new staff is educated on dealing with aggressive residents whether that be an in person or an online training. With respect to what systemic measures have been put into place to address the stated concern: Director of Clinical Services and Executive Director will review training modules to ensure that education on dealing with aggressive residents, whether that be an in person or an online training, is ongoing for all staff. With respect to how the Plan of Correction will be monitored: Human Resources will review staff records for completion of required training, quarterly.
Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documentation and interview, the facility failed to have staff adequate in knowledge, skills, and abilities to maintain the physical, mental, and psychosocial well-being of each resident. Evidence: Resident #1?s ISP, dated 6/8/23, states that she can exhibit aggressive, abusive, disruptive, or agitated behavior. Staff members are to intervene before it escalates or back away and attempt care at a later time when Resident #1 is less agitated. Staff #4 signed a violence free acknowledgement form that states that the staff member does ?understand that if I believe I have been witness to or victim of threats, harassment and aggressive, violent, or inappropriate behavior that I have a duty to notify a supervisor, or Executive Director, immediately.? Staff #4?s statement, dated 7/27/23, included information about her witnessing Staff #5 holding Resident #1?s wrists and that she did not tell anyone about this. Staff #4?s statement also includes information about her hitting Resident #1 in the buttocks, and also witnessing Staff #3 hitting the resident in the buttocks. Staff #7 was interviewed during the inspection, and he reported that the staff member did not report the incidents to a supervisor or Executive Director.
Plan of Correction:	In respect to the specific resident/situation cited: Staff Members # 1, 2, 3, 4, 5, and 6 have been terminated. In respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and Executive Director will review training modules to ensure that current staff is educated on mandated reporting and change of condition, whether that be an in person or an online training. With respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services and Executive Director will review training modules to ensure that education on mandated reporting and change in condition for staff is ongoing, whether that be an in person or an online training. With respect to how the Plan of Correction will be monitored: Human Resources will review staff records for completion of required training, quarterly.
Standard #:	63.2-1808-A-10
Complaint related:	Yes
Description:	Based on observation and documentation, the facility failed to ensure that each resident is free from physical abuse. Evidence: Resident #1?s individualized service plan (ISP), dated 6/8/23, states that the resident exhibits aggressive, abusive, disruptive, and agitated behavior. The ISP also states that Resident #1 resists or refuses care. The ISP states that staff members should remain calm and stay out of the resident?s reach, when Resident #1 becomes agitated. The ISP also states that staff members should listen and respond with empathy while calmly engaging the resident in conversation. The ISP also instructs staff to back away and attempt care at a later time, when Resident #1 becomes combative in the community. Videos, taken from Resident #1?s room, were observed involving Resident #1 and her interactions with several staff members. In a video, dated 7/18/23, Staff #2 is observed hitting Resident #1 in the face with an article of clothing. In a video, dated 7/20/23, staff members were observed pulling Resident #1?s wrists and slapping the resident?s leg. In a video, dated 7/21/23, Staff #4 is observed slapping Resident #1 on the buttocks. The other staff member in the video, Staff #5, is observed pulling Resident #1 by her wrists. In another video, dated 7/24/23, Resident #1 was being assisted in the bathroom. Staff #4 was observed stepping on Resident #1?s foot. Staff #5 completed a statement, dated 7/27/23, confirming that he held Resident #1?s wrists. Staff #4 completed a statement, dated 7/27/23, confirming that she observed Staff #5 holding Resident #1?s wrists. Staff #4?s statement says that she has hit Resident #1 on the buttocks, and that she has observed Staff #3 also hit Resident #1 on the buttocks.
Plan of Correction:	In respect to the specific resident/situation cited: Staff Members # 1, 2, 3, 4, 5, and 6 have been terminated. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical Services and Executive Director will review residents with aggressive behavior service plan to ensure that it guides staff in a manner that protects themselves and the resident. With respect to what systemic measures have been put into place to address the stated concern: Staff has been in-serviced on mandated reporting, abuse and neglect and residents? rights. With respect to how the Plan of Correction will be monitored: Residents identified during review, will be discussed during weekly interdisciplinary meeting