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: Sept. 9, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

The inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 9/9/20 and concluded on 11/2/20. A self-reported incident was received by the department regarding allegations in the area of: Resident Care and Related Services. The director of nursing was contacted by email to conduct the investigation. The licensing inspector emailed the director of nursing a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on documentation and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: The record, for Resident #1, contains an assessment of serious cognitive impairment, dated 8/31/18, that states that the resident is unable to recognize danger and protect her own safety and welfare. The assessment reports that Resident #1 has severe dementia, which affects her cognitive functioning. The assessment is required, prior to a resident's placement into the facility's secure unit. The secure unit requires the entry of a pass code, to exit without triggering an alarm on the delayed-egress door. Resident #1's UAI (uniform assessment instrument), dated 11/7/19, notes that the resident wanders throughout the community. Facility reporting indicates that Resident #1 was observed in a hallway at 5:45 PM on 9/8/20. According to a law enforcement report, Resident #1 was wandering around a store at 6:11 PM. The store is located approximately one mile away from the facility. Store staff reported that Resident #1 appeared confused and she did not know her name. Store staff reported that they contacted law enforcement after Resident #1 reported that her mother brought her to the store. A law enforcement report stated that Resident #1 was able to provide them with her first name, but not her address. An officer took Resident #1's picture to the facility and a staff member confirmed that Resident #1 lived there. Facility reporting indicates that law enforcement brought Resident #1 back to the facility at 7:00 PM on 9/8/20.
Plan of Correction:	All gates, exit doors, alarm functions checked periodically throughout the day by the BSM to ensure they are secure. All residents are on 1 hour documented safety checks by the direct care staff. The courtyard is checked and documented every 15 minutes by direct care staff. The lobby door to the secure area has had the delay shortened from 12 to 7 seconds for someone to exit once the code is entered. Staff have been inserviced on checking behind themselves when they exit the secure community to ensure resident has not exited behind them.