VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Richmond)
13800 Bon Secours Drive
Midlothian, VA 23114
(804) 378-5100

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Sept. 29, 2022

Complaint Related: No

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/29/2022 at approximately 11:12a.m until 12:26p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/25/2022 regarding allegations in the area of Personnel. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. N/A Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: While onsite at the facility on 09/29/2022 the inspector interviewed the current facility Administrator via telephone. An exit meeting will be conducted to review the inspection findings. 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-150-A
Description:	Based on the interviews conducted the facility failed to ensure that the facility had an administrator of record. Evidence: For thirty-five (35) days beginning 08/25/2022 until 09/27/2022-while residents were in care the, facility did not ensure that a licensed facility Administrator was onsite and responsible for the day to day operation of the facility.
Plan of Correction:	FACILITY'S RESPONSE: "RDO and/or designee of ProMedica will provide written notice via email within 14 days to alert both Virginia Department of Social Services as well as the Board of Long Term Care Administrators of the absence of the facilities licensed administrator. This notice to both DSS and the Board of LTCA will include the last working day of the previous licensed administrator and will identify who is their replacement. The RDO and/or designee will ensure that a Board of Long Term Care Administrators approved Administrator/Acting Administrator/Acting Administrator in Training is submitted to the Department of Social Services."
Standard #:	22VAC40-73-150-B-3
Description:	Based on the review of emails received at the department and interviews conducted- a facility licensed for both residential and assisted living care, when an acting administrator is named, he must submit a completed application for an approved administrator-in-training program to the Virginia Board of Long-Term Care Administrators within 10 days of employment. Evidence: On 08/25/2022 the Regional Director of Operations for the facility notified the department that the facility Administrator resigned the position effective 08/25/2022 and that facility staff # 1 had been appointed as the Interim Executive Director effective August 25 , 2022. The 08/25/2022 email also informed that facility staff #2 also an LPN is currently working with (Preceptor identified) for AIT Training) and will be the backup for facility staff #1. Upon request for the inspector?s review the facility did not submit documented evidence that a completed application for an approved administrator-in-training program was submitted to the Virginia Board of Long-Term Care Administrators within 10 days of employment on behalf of facility staff #s 1 and 2.
Plan of Correction:	FACILITY'S RESPONSE: "The RDO and/or designee of ProMedica will ensure that a Board of Long Term Care Administrators approved Administrator/Acting Administrator/Acting Administrator in Training is submitted to the Department of Social Services for approval as Administrator/Acting Administrator/Acting Administrator in Training within 10 days of employment."