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: Aug. 9, 2023

Complaint Related: No

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: 08/04/2023 approximate time 8:54a.m-2:19p.m and 08/09/2023 approximate time 8:44a.m-3:48p.m 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: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 7 Observations by licensing inspector: Medication pass observed on 08/09/2023 Additional Comments/Discussion: 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 Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1180-B
Description:	When there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 08/09/2023: On the interior courtyard of the Dogwood and Monument units the inspector accompanied by facility staff #4 pointed out the exposed irrigation tubes in a section near the exit/entrance of the units.
Plan of Correction:	Building Service Coordinator will be educated I nd trained on this code. The BSC will preform weekly courtyard inspections to ensure no harmful objects are in the courtyard. Irrigation tubes were covered at survey. Administrator/designee will preform courtyard inspections weekly for 3 months.
Standard #:	22VAC40-73-210-B
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that all direct care staff attended at least 12 hours of training annually. Evidence: Facility records submitted for the inspector?s review is not documented to note that staff #s 1,2 and 4 obtained the required annual staff develop training hours as required.
Plan of Correction:	Facility Business Coordinator office will be educated and trained on this , ode and business office will review and ensure all direct care staff have annual records for 12 hours df training and will put it in their employee file per code. Staff number 1,2,4 are all up to date as of 10/11/1 3. Administrator/designee will audit 5 random files each month for 3 months.
Standard #:	22VAC40-73-250-D
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that each staff person required to be evaluated annually submitted the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #1-Documented date of hire 08/19/2021 Staff #2-Documented date of hire 02i19/2022 Upon request during the 08/09/2023 renewal inspection the facility did not submit for the inspector's review documented evidence that facility staff #1 had an annual risk assessment, documenting that the individual is free of tuberculosis in a communicable form.
Plan of Correction:	Facility Business Coordinator will be educated and trained on this code and business office will review and ensure all facility staff have completed an annual TB risk assessment and it is placed in their employee file per code. Facility business office will keep a running list of when TB assessments are due. Staff number one has a completed TB annual assessment in her file. Administrator/designee will audit 5 random files each month for 3 months.
Standard #:	22VAC40-73-260-A
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that each direct care staff member maintained 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. The certification must either be in adult first aid or include adult first aid. Evidence: Staff #s 1, 2, 3 Upon request during the 08/09/2023 renewal inspection the facility did not submit for the inspector's review documented evidence that facility staff #s 1, 2 and 3 had current first aid certification.
Plan of Correction:	Facility Business Coordinator will be educat d and trained on this code and business office will review and ensure all direct care staff have first aid training and this is placed in their employee chart per code. Facility Business office will keep a running list bf when first aid training is due. Staff 1,2,3 all have updated first aid information in their employee files. administrator/designee will audit 5 random files each month for 3 months.
Standard #:	22VAC40-73-450-A
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care (ISP) was developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #1-Documented date of admission 08/03/2023 Upon request during the 08/09/2023 renewal inspection the facility did not submit for the inspector's review documented evidence that a preliminary ISP was developed for the resident prior to or since admission
Plan of Correction:	RSC will be educated and trained on this code and nursing will develop a preliminary plan of care (ISP) is developed on or within 7 days prior to admission to address basic needs of the resident. Resident 1 has an up to date ISP. Administrator/designee will audit 2 random new admits care plans each month for 3 months.
Standard #:	22VAC40-73-660-A
Description:	Based on observation the facility failed to ensure that the medication storage area was locked. Evidence: Accompanied by the facility Administrator during the walk through of the Capital unit of the facility on 08/04/2023, the inspector informed the Administrator that the medication cart was not locked. There was no staff near the unlocked cart and residents were ir:i the area where the unlocked cart was being stored.
Plan of Correction:	All staff that pass medications will be educat d and trained on this code by RSC/designee. Administrator /designee will perform spot checks at rand! m times daily to ensure medication cart is locked while staff is not near the cart.
Standard #:	22VAC40-73-690-F
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that all of the requirements of this subdivision are maintained in the facility files for at least two years, with any specific recommendations regarding a particular resident also maintained in the resident's record. Evidence The facility's 06/12/2023 Consultant Pharmacist's Quarterly Activity Report that was submitted for the inspector's review did not contain subdivisions E 1 through E 11. Upon request during the onsite renewal inspection conducted on 08/04, 09/2023 the facility did not submit for the inspector's review documented evidence that a medication review was conducted as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-720-A
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest is included in the individualized service plan (ISP). Evidence: Resident #2 The resident's 07/23/2023 ISP that was submitted for the inspector's review on 08/09/2023 is not documented to note that the resident has a signed DNR on file at the facility or the responsibility of facility staff to fulfil the DNR order.
Plan of Correction:	RSC will be educated and trained on this co e. The RSC will ensure that all residents with DNRs have it listed in their ISP. Administrator/designee will audit 2 ISPs per month for 3 months.