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. 29, 2023

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: 11/29/2023 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: 57 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: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. 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 #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications. Evidence: 1. The following expired medications were observed in the medication carts at the facility: PRN Promethazine HCL 12.5 mg tablets expired 11/3/23 for Resident #5, PRN Lorazepam .5 mg tablets expired 7/4/23 for Resident #7, PRN Risperidone .25 mg tablets expired 7/25/23 for Resident #8, PRN Loperamide 2 mg capsules expired 9/21/23 for Resident #9, PRN Hyoscyamine Sulfate .125 mg tablets expired 9/2/23 for Resident #10, PRN Docusate Sodium 100 mg soft gels expired 6/30/22 and PRN Melatonin 3 mg tablets expired 7/26/23 for Resident #11, Omeprazole 40 mg capsules expired 9/30/23 for Resident #12, PRN Loperamide 2 mg capsules expired 11/1/23 for Resident #13, PRN Acetaminophen 325 mg tablets expired 7/31/23 for Resident #14, PRN Acetaminophen 325 mg tablets expired 10/31/23 for Resident #15, 2 cards of PRN Acetaminophen 325 mg tablets expired 6/30/23 (1 card) and 10/31/23 (1 card) for Resident #16, and a bottle of Essential C Complex capsules expired 10/23 for Resident #17.
Plan of Correction:	The Executive Director, RSC, Nursing Staff and Medication Aides will be re-educated on state regulation 22VAC40-73-640-A. Medication Management plan and reference materials related to methods to prevent the use of outdated, damaged, or contaminated medications. RSS will complete a weekly cart audit with RSC or designee to ensure compliance with 22VAC40-73-640-A-3. RSC or designee will complete a monthly cart audit with ED to ensure compliance with 22VAC-73-640-A-3.
Standard #:	22VAC40-73-700-3
Description:	Based on observation, the facility failed to ensure that only oxygen from a portable source be used by residents when they are outside their rooms. The use of long plastic tether lines to the source of oxygen outside their rooms is not permitted. Evidence: 1. During a tour of the facility, Resident #12 was noted in a common dining area with an oxygen concentrator with a long plastic tether line.
Plan of Correction:	The Executive Director, RSC and all clinical staff will be re-educated on state regulation 22VAC40-73-700-3. Executive Director, RSC or designee will complete an audit of all residents who use oxygen outside of their living quarters on a monthly basis to ensure compliance with 22VAC40-73-700-3.