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: Nov. 16, 2023

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 GROUNDS 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: 11/6/23 Number of residents present at the facility at the beginning of the inspection: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 8 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activity 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 #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that a review of continued appropriateness, for the special care unit, is completed six months after placement and annually thereafter. Evidence: The records of Residents #1 and #5 did not contain a review of continued appropriateness, for the special care unit, that was completed within the past year. Resident #1?s most recent review of continued appropriateness was completed in August 2021. Resident #5?s most recent review of continued appropriateness was completed in February 2021.
Plan of Correction:	Residents #1 and #5 were reviewed for continued appropriateness for the special care unit. The Resident Service Coordinator will be educated on the review for continued appropriateness for the special care unit to be completed 6 months after placement and annually thereafter. The Executive Director or designee will validate resident records for the required review of the continued appropriateness for the special care unit.
Standard #:	22VAC40-73-210-G
Description:	Based on record review, the facility failed to ensure that documentation of training received is kept in the staff record. Evidence: Training records were requested during the inspection. No documentation of completed training for Staff #1, #2, #3, or #4, were provided during the inspection.
Plan of Correction:	Staff #1, #2, #3, and #4 training records were reviewed and updated. The Executive Director was educated on maintaining training documentation in each staff members record. The Executive Director or designee will review staff records to validate training records are present.
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 annually. Evidence: Tuberculosis risk assessments, completed within the past year, were not provided for Staff #1, #2, or #4. Staff #1?s record contained a tuberculosis test form, dated 7/26/23, but it was not completed. The most recent tuberculosis risk assessment provided for Staff #2 was dated 9/21/21. The most recent tuberculosis risk assessment provided for Staff #4 was dated 9/13/21.
Plan of Correction:	Staff #1, #2, and #4 have TB risk assessments completed. The Administrative Service Coordinator will be educated on the necessity of a TB assessment annually. The Executive Director or designee will review staff records to validate TB risk assessments are present.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that each resident?s physical examination, completed within the 30 days preceding admission, includes all of the required information. Evidence: The physical examination for Resident #3, dated 12/1/22, did not include: a tuberculosis risk assessment, a statement about prohibited conditions, the resident?s ambulatory status, or an indication about the resident?s ability to self-administer medication. No physical examination was provided, during the inspection, for Resident #8.
Plan of Correction:	Resident #3 and #8 physical examination was completed. The Resident Service Coordinator was educated on the completion of physical examination with all of the required information within 30 days preceding admission. The Executive Director or designee will audit new move in resident records to validate the completion of a complete physical examination.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that each resident receives a tuberculosis risk assessment annually. Evidence: The records of residents #2 and #5 did not contain the results of a tuberculosis risk assessment that was completed within the past year. Risk assessment forms were present in the resident records, but the results of the risk assessment were not documented.
Plan of Correction:	Resident #2 and #5 TB risk assessment forms were completed. The Resident Service Coordinator will be educated on the TB risk assessment process and completion of forms. The Resident Service Coordinator or designee will audit resident records weekly times 4 weeks to validate TB risk assessment completion.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure that the private pay uniform assessment instrument (UAI) is approved by the administrator. Evidence: The UAIs for Resident #6 (8/29/23) and Resident #7 (5/31/23) were completed by a facility staff member. The UAIs for Residents #6 and #7 were not signed/approved by the facility?s administrator.
Plan of Correction:	Resident #6 and #7's UAI was signed and approved by the Executive Director. The Executive Director was educated on the signature and approval of UAIs The Executive Director or designee will review new move in resident's record to validate that UAI approval or signature is present by the Executive Director.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that individualized service plans (ISPs) are signed and dated by the administrator, or their designee, and by the resident or their legal representative. Evidence: The ISP for Resident #1, dated 4/13/23, was not signed by the resident or their legal representative.
Plan of Correction:	The Executive Director or designee will review the ISP with Resident #1's family and obtain appropriate signatures. The Executive Director will be educated on the ISP review process to include obtaining all necessary signatures. The Executive Director or designee will audit ISPs weekly times 4 weeks for signatures.
Standard #:	22VAC40-73-450-G
Description:	Based on record review, the facility failed to ensure that the master service plan is filed in the resident record. Evidence: The individualized service plans (ISPs) for Residents #3 and #6 were not included in the resident record.
Plan of Correction:	Resident #3 and #6 Master Service Plan was placed in the resident record. The Resident Service Coordinator was educated on the timely filing of master service plans in resident records. The Executive Director or designee will audit 5 resident records weekly times 4 weeks to validate master service plans are present.
Standard #:	22VAC40-73-520-I
Description:	Based on observation, the facility failed to ensure that the monthly schedule of activities is posted in a conspicuous location in the facility. Evidence: No monthly activity schedule was posted in the facility at the time of the building walkthrough. A daily schedule was posted near the facility?s activity area by noon, but the monthly schedule was not posted.
Plan of Correction:	The facility posted the monthly activity schedule on 11/16/23. The Program Service Coordinator will be educated on the timely ordering and posting of activity calendars. The Executive Director or designee will audit activity calendars weekly times 4 weeks for appropriate posting.
Standard #:	22VAC40-73-620-A
Description:	Based on documentation, the facility failed to ensure that a dietitian or nutritionist completed an oversight of special diets, for each resident who has such a diet, every six months. Evidence: The most recent oversight of special diets, completed by the dietitian/nutritionist, was dated 4/15/23. The oversight was more than six months old, at the time of the inspection.
Plan of Correction:	The Dietitian will complete a review of each resident's diet. The Executive Director was educated on the dietitian/nutritionist oversight necessary every 6 months. The Executive Director or designee will audit resident records to validate Dietitian/Nutritionist oversight is present.
Standard #:	22VAC40-73-950-E
Description:	Based on documentation, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. Evidence: The most recent documented review of the emergency preparedness plan with staff, residents, and volunteers was completed on 4/21/23. The review was more than six months old, at the time of the inspection.
Plan of Correction:	The Executive Director will review the emergency preparedness and response plan for all staff residents, and volunteers. The Executive Director will be educated on the emergency preparedness and response plan review needed every 6 months. The Executive Director or designee will validate that the appropriate documentation is in place for the Emergency Preparedness and response plan review is in place.
Standard #:	22VAC40-80-120-E-5
Description:	Based on observation, the facility failed to ensure that a copy of the special order and a copy of the notice of intent are posted in a prominent place at each public entrance. Evidence: The commissioner?s notice of intent letter, dated 3/28/23, and the special order, dated 4/27/23, were not posted in a prominent place at each public entrance at the initiation of the inspection. The Notice of Intent and the Special Order document are to be posted in a prominent place at each public entrance for a period of twelve (12) months.
Plan of Correction:	The Notice of Intent and the Special Order document was posted in a prominent public location on 11/16/23. The Executive Director was educated on the appropriate placement of commissioner's notices. The Executive Director or designee will validate that the commissioner's notice is present in a prominent and public place.
Standard #:	22VAC40-90-40-B
Description:	Based on documentation, the facility failed to obtain a criminal history record report within 30 days of each employee?s hire date. Evidence: Background checks for new employees, hired since the last inspection, were reviewed during the inspection. The record for Staff #5 (hired 3/22/23) contained a background check that was dated 7/9/23. The background check was not completed within 30 days of Staff #5?s hire date.
Plan of Correction:	Staff #5 had a background check on 7-9-23 The Administrative Service Coordinator will be educated on obtaining background checks for new hires within 30 days of each employees hire date. The Executive Director or designee will audit new hire background checks weekly times 4 weeks to validate timeliness.