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: Feb. 16, 2022 and March 21, 2022

Complaint Related: Yes

Areas Reviewed:

PART II: ADMINISTRATION AND ADMINISTRATIVE SERVICES PART VI: RESIDENT CARE AND RELATED SERVICES PART X: ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Unannounced complaint inspections were conducted in response to a complaint that was received by the licensing office on 1/26/22 regarding: Administration and Administrative Services, Resident Care and Related Services, and Staffing. Four resident records and facility documentation were observed. The allegations were determined to be valid, as a preponderance of evidence supported the allegations. The 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, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that there were enough direct care staff members, awake and on duty, during night hours. Evidence: Facility staffing schedules and census documents were reviewed during the inspection. The resident census was between 41 and 50, from 1/1/22 until 2/15/22. The staffing schedule indicates that the facility did not have at least five staff members, awake and on duty, on the following night shifts: 1/6/22 (four staff members), 1/15/22 (four staff members), and 2/23/22 (four staff members).
Plan of Correction:	The Resident Services Coordinator will follow the staffing model ensuring proper staffing levels. Resident Services Coordinator or designee will review the staffing schedule with the Executive Director to make sure the staffing model is being followed. Resident Services Coordinator or designee will review the staffing schedule with the Executive Director or designee daily to ensure compliance with staffing model, that the master schedule is being followed and sufficient staff are available for care needs. Resident Services Coordinator or designee will review care schedule daily to ensure accuracy, address any changes that may be needed. Will review the daily staffing sheet before the end of their shift to confirm all staff are present and working in their designated area.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on record review and observation, the facility failed to document the circumstances involved and the notification of a resident's legal representative, when a resident suffers an injury. Evidence: Resident #1 was observed to have bruising on her knuckles on 2/16/22. Facility documentation noted treatment to the resident's left hand on 2/12/22. No documentation was found, in the resident record, to document the circumstances involved or the notification of Resident #1's legal representative.
Plan of Correction:	Nursing and direct care staff will received training from the ED and RSC on the incident notification process. Resident Services Coordinator and Executive Director and/or designee will continue to audit incident reports to ensure completion and ensure communication to family. Continue to create incident reports times and make the appropriate notifications. Executive Director, Resident Services Coordinator, or designee will review daily all incidents and incident reports that have occurred in the past 72 hours and will also ensure accuracy and proper notification to responsible party. They will ensure accuracy and proper notification to resident's responsible party. The RSC will oversee the resident incident process for compliance.