VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Annandale)
7104 Braddock Road
Annandale, VA 22003
(703) 256-0882

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: May 3, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES2VAC40-73 GENERAL PROVISIONS 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 ADULT 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:

An unannounced renewal inspection was conducted on 5/3/22. At the time of entrance, 49 residents were in care. A meal, medication administration, and an activity were observed. Building and grounds were inspected. 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 #:	22VAC40-73-660-B
Description:	Based on observation and record review, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAI has indicated that the resident is capable of self-administering medication. Evidence: Calmoseptine ointment, ordered 12/22/21 for Resident #5, was observed to be unlocked and unattended in the resident?s bathroom cabinet. Resident #5?s UAI, dated 4/9/22, states that he needs his medication to be administered by professional nursing staff.
Plan of Correction:	Calmoseptine ointment, found in the bathroom cabinet of Resident #8, was immediately removed during the inspection visit on May 3, 2022. RSC and/or designee will inspect Resident rooms ensure medications/dietary supplements have been not been stored unlocked or unattended. RSC and/or designee will provide training and/or retraining to all employees with routine access to Resident rooms. Employees will be instructed to remove any medications/dietary supplements observed in Resident rooms immediately. Employees will be instructed to give any medications/dietary supplements found, unlocked or unattended, to the LPN on duty. 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 impromptu inspections of Resident rooms, to include nightstands/dresser drawers, closets and, bathroom cabinets, to ensure medications/dietary supplements have been not been stored unlocked or unattended. A qualified healthcare provider will conduct impromptu inspections of Resident rooms, to include nightstands/dresser drawers, closets and, bathroom cabinets, to ensure medications/dietary supplements have been not been stored unlocked or unattended.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and documentation, 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 medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Medication administration for Resident #3 was observed during the inspection. Resident #3 was administered Vitron-C shortly after 9:00 AM. The instructions for Vitron-C, ordered 1/18/22 for Resident #3, stated that it should be given on an empty stomach. Breakfast is served at 8 AM and facility staff reported that Resident #3 ate breakfast, before the Vitron-C was administered. The MAR for Resident #7 was reviewed. Resident #7 has her blood sugar (BS) checked three times per day, and the MAR calls for her to receive insulin units (U) based on a sliding scale. Resident #7?s MAR included the following sliding scale for insulin administration: 2U (BS= 201-250), 4U (BS= 251-300), 6U (BS= 301-350), 8U (BS= 351-400) The MAR included the following administration of insulin for Resident #7: 4U (BS= 308) on 4/16/22 at 5 PM Zero units (BS= 339) on 4/17/22 at 8 AM 2U (BS= 286) on 4/22/22 at 6 PM 4U (BS= 306) on 4/26/22 at 8 AM 4U (BS= 248) on 5/1/22 at 8 AM 2U (BS= refused) on 5/1/22 at 5 PM
Plan of Correction:	Time of medication administration of the Vitron-C for Resident #3 was corrected the same day as the inspection, May 3, 2022. The Resident Services Coordinator (RSC), amended the administration time on the MAR from 9:00am to 6:30am. The pharmacy will make a correction to the medication administration time on the June 2022 MAR and each MAR thereafter. RSC communicated medication time change to all LPN?s and Medication Technicians (MT) responsible for administering the Vitron-C to Resident #3. RSC provided re-training to LPN?s and MT?s on sliding-scale insulin administration as written in accordance with the physician?s or other prescriber?s orders. RSC and/or designee will conduct impromptu audits of medications and MAR?s to ensure all medications are transcribed and administered as written/prescribed in accordance with the physician?s or other prescriber?s instructions. RSC and/or designee will provide training and/or retraining to LPN?s and MT?s on the transcription and administration of prescribed medications in accordance with the physician?s or other prescriber?s instructions. 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 impromptu audits of medication administration and MAR?s to ensure all medications are transcribed and administered in accordance with the physician?s or other prescriber?s instructions. During the quarterly healthcare oversight, a qualified healthcare provider will conduct impromptu audits of medication administration and audit MAR?s to ensure all prescribed medications are transcribed and administered in accordance with the physician?s or other prescriber?s instructions.
Standard #:	22VAC40-73-680-M
Description:	Based observation and documentation, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: PRN Acetaminophen, ordered 10/18/18 for Resident #8, was not available for administration during the inspection. A package of the medication was at the facility, but it expired on 4/30/22
Plan of Correction:	The PRN Acetaminophen for Resident #8 was removed from the medication cart the same day as the inspection, May 3, 2022. A refill order for the PRN Acetaminophen for Resident #8 was sent to the pharmacy on May 3, 2022 and arrived the following day, May 4, 2022. RSC provided re-training on the timely removal of expired PRN medications to all LPN?s and MT?s. RSC and/or designee will audit medication carts and review expiration dates of PRN medications. Any expired PRN medications will be removed and replaced as prescribed in accordance with the physician?s or other prescriber?s instructions. RSC and/or designee will conduct a weekly audit of medication carts and review expiration dates of PRN medications. Any expired PRN medications will be removed and replaced as prescribed in accordance with the physician?s or other prescriber?s instructions. RSC, Executive Director or designee will conduct impromptu audits of medication carts and review expiration dates of PRN medications. Any expired PRN medications will be removed and replaced as prescribed in accordance with the physician?s or other prescriber?s instructions. A qualified healthcare provider will conduct impromptu audit of medication carts and review expiration dates of PRN medications during the quarterly healthcare oversight.