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: July 28, 2022 , Aug. 12, 2022 , Sept. 8, 2022 and Oct. 19, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) the licensing inspector was on-site at the facility for each day of the inspection: 7/28/22, 8/12/22, 9/8/22, 10/19/22. 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 7/15/22, regarding allegations in the area(s) of: Administration and Administrative Services 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 #:	22VAC40-73-100-A
Complaint related:	Yes
Description:	Based on documentation, the facility failed to implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines. Evidence: The CDC?s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic calls for facilities to ensure everyone is aware of recommended IPC practices in the facility, including visual alerts about the current IPC recommendations (e.g., when to use source control and perform hand hygiene). The CDC defines source control as the ?use of respirators, well-fitting facemasks, or well-fitting cloth masks to cover a person?s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.? The guidance also states that facilities should optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals (e.g., physical barriers at reception / triage locations and dedicated pathways to guide symptomatic patients through waiting rooms and triage areas). The CDC recommends the use of ?NIOSH-approved particulate respirators with N95 filters or higher? when providing care for patients with suspected or confirmed SARS-CoV-2 infection. Facility visitor guidelines report that indoor visitation will be allowed for all residents regardless of vaccination status. The visitor guidelines also state that indoor visitation during an outbreak investigation will be allowed, and that visitors should be aware of the potential risk of visiting during an outbreak investigation and adhere to the core principles of infection prevention. Visitor guidelines also state that residents and visitors should wear face masks during visits, regardless of vaccination status and visits should occur in the resident?s room. No information was included in the visitation guidelines to inform visitors that source control devices should not be placed on children under age 2, anyone who cannot wear one safely, such as someone who has a disability or an underlying medical condition that precludes wearing one safely, or anyone who is unconscious, incapacitated, or otherwise unable to remove their source control device without assistance. The facility?s COVID-19 Clinical Monitoring and Measures Plan calls for patients to remain in transmission based (airborne-droplet) precautions until they meet symptom-based recovery criteria, if they test positive. Facility staff reported that visitors are instructed to meet with the facility nurse or Resident Care Director at the wellness office, after completing the COVID pre-screening and before visiting with any residents. The facility?s wellness office is located in the memory care unit. Facility documentation stated that Resident #1 tested positive for COVID on 7/11/22. Documentation in Resident #1?s record states that she was wandering the halls of the memory care unit on 7/14/22. A visitor, for Resident #1, reported that the resident was not wearing a mask while she was wandering the halls. Resident #1 was not documented as meeting the symptom-based recovery criteria.
Plan of Correction:	Executive Director (ED) will consult with appropriate personnel at Corporate Office to discuss including additional information to current visitor guidelines to ensure complete understanding of the potential for increased risk of exposure to SARS-CoV-2 due to the impaired cognitive abilities of our Memory Care Residents. Information will be provided to visitors, in writing and/or verbally that, due to their diagnosis of Alzheimer?s and/or other dementias, Residents of Arden Courts of Annandale, lack the cognitive ability to comprehend and/or follow certain CDC guidelines for infection control as they relate to SARS-CoV-2. These guidelines include, but are not limited to individual masking, social distancing, isolation precautions and remaining in transmission based (airborne-droplet) precaution until they meet symptom-based recovery criteria if, they test positive.
Standard #:	22VAC40-73-470-F
Complaint related:	No
Description:	Based on documentation, the facility failed to ensure that notification to a resident?s physician, next of kin, legal representative, or designated contact person is documented after a resident suffers from a serious accident, injury, illness, or medical condition. Evidence: Resident notes indicate that Resident #2 (7/11/22), Resident #3 (7/12/22), and Resident #4 (7/12/22) tested positive for COVID-19. There was no documentation in the records of Residents #2, #3, or #4 to indicate that their next of kin or legal representatives were notified of the positive tests.
Plan of Correction:	Resident Services Coordinator (RSC) and/or shift LPN contacted the next of kin or legal representatives of the 16 Residents who tested positive for COVID on July11, 2022 to inform them of the COVID positive test results and answer any potential questions. However, the appropriate notification documentation was not completed for 3 of the 16 Residents who tested positive. Executive Director and/or RSC will provide training and/or retraining to all LPN?s on appropriate and timely documentation of notification to Residents? next of kin or legal representatives for compliance of state regulations. A late entry was entered into the records, by the nurse who spoke directly to the next of kin or legal representatives, of the 3 COVID positive Residents? records as part of the corrective action taken.