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: June 16, 2023

Complaint Related: Yes

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: On 06/08/2023 approximate time 9:25a.m-12:45p.m. On 06/16/2023 approximate time 10:02a.m-1:39p.m. 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 01/20/2023 regarding allegations in the resident care and related services, staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 5 Observations by licensing inspector: Technical assistance offered. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Staffing and supervision A violation notice was 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. 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 angeal.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	No
Description:	Based on the review of facility records and staff interviews the assisted living facility failed to ensure that except during night hours, when 20 or fewer residents are present, at least two direct care staff members must be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. (1)-On 01/20/2023 the facility did not staff each cognitively impaired unit during the evening shift (3p.m-11p.m) with the 2 staff members that would be responsible for the care and supervision of 20 cognitively impaired residents as required. Staff #2 was assigned to both Capital and Monument units from 3-11p.m on this date. From 8p.m until change of shift at 11p.m facility staff #2 was the only direct care staff assigned to work both Capital and Monuments units. . (2)-On 01/25/2023 the facility did not staff each cognitively impaired unit during the evening shift (3p.m-11p.m) with the 2 staff members that would be responsible for the care and supervision of 20 cognitively impaired residents as required. From 8p.m until change of shift at 11p.m facility staff #3 was the only direct care staff assigned to work the Dogwood unit on this date. From11p.m-7a.m on 01/25/2023 staff #9 was the only direct care staff assigned to work on the Capital unit. Staff #9 is also identified as the only medication aide for the Capital and Monument units. From 11p.m-7a.m staff #11 is identified as the only direct care staff assigned to work the Monument on this date. (3)- On 01/27/2023 the facility?s Daily Census report document notes the census as 32 residents in care. From 7p.m until change of shift at 11p.m facility staff #6 was the only direct care staff assigned to work the Capital unit on this date. From 8p.m until change of shift at 11p.m facility staff #7 was the only direct care staff assigned to work the Dogwood unit on this date. From 7p.m until change of shift at 11p.m facility staff #8 was the only direct care staff assigned to work the Monument unit on this date. A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Angela Rodgers-Reaves Date Violation Notice Issued: 8/3/2023 From 11p.m-7a.m facility staff #s 12, 13 and 14 were the only direct care staff assigned to provide care, services and supervision to 32 residents.
Plan of Correction:	FACILITY RESPONSE: " The Administrator and Director of Nursing-RSS will review the schedule to ensure adequate staffing for the facility." "The facility will fill its vacant positions and ensure open positions to be filled will meet DSS guidelines." "The facility will continue to monitor direct care staffing requirements based on occupancy for evening-night shift to ensure regulations are met or exceeded."