VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Virginia Beach)
1853 Old Donation Parkway
Virginia beach, VA 23454
(757) 412-1180

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Nov. 1, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/01/2022 from 8:47 am to 1:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-200-C
Description:	Based on record review and interview, the facility failed to ensure direct care staff meet one of the requirements in this subsection. Evidence: 1. Staff #1 works at the facility as direct care staff; however, their record only includes an expired CNA license as of 06/30/2022. 2. Staff #4 works at the facility as direct care staff; however, their record only indicates Staff #4 has a Temporary Nurse Aide 8 hour training certificate as of 01/27/2022. 3. Staff #5 acknowledges the facility does not have a current certificate issued or other documentation indicating Staff #1 and Staff #4 meet one of the requirements of direct care staff in their records.
Plan of Correction:	Staff #1 has completed her renewal and has current C.N.A. license. Staff #4 will complete the 40 hour Direct Care Course by 11/23/2022. Staff #5 will complete quarterly audits of personnel records and update as needed.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #4 (hired 07/18/2022) work as direct care staff and does not have a current certification in first aid.
Plan of Correction:	Staff #4 received her CPR and First Aid Certification on 11/5/2022.
Standard #:	22VAC40-73-520-I
Description:	Based on observation and interview, the facility failed to ensure the activity schedule for the current month be posted in a conspicuous location in the facility. Evidence: 1. On the day of the inspection, the November 2022 activity calendar for the facility was inaccessible and not posted in a conspicuous location in the facility.
Plan of Correction:	Activity calendar for November 2022 was completed and posted on 11-2-22 by 8:00 am. Each neighborhood had a daily activity schedule posted on 11-1-22. November 2022 calendar submitted to DSS inspector on 11-2-22 in the am.
Standard #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure the medication cart be locked. Evidence: 1. During a medication observation, Staff #3 left the medication cart unlocked and unattended from approximately 8:55 am to 9:06 am.
Plan of Correction:	Charge nurse or designee will verify the medication cart is locked three times per shift for one week, then twice per shift for one week then random checks weekly.