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: Dec. 27, 2024

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 12/27/2023 approximate time 12:08p.m-4:51p.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 12/11/2023 regarding allegations in the areas of staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility on12/27/2023. Number of resident records reviewed: 3 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch time meal was observed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the noncompliance with standards or law. However, violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can 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 Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on the review of facility records and staff interviews the facility failed to conduct a reassessment due to a significant change in the resident's condition, using the UAI, to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: Resident #1 Upon request to review the resident?s most recent UAI the facility submitted a 08/03/2023 UAI. The review of the UAI revealed inconsistencies with the assessed needs of the resident. he 08/03/2023 UAI notes that the resident needs no help with toileting, transferring, eating/feeding, and with bowel and bladder. The 08/03/2023 UAI also notes that facility staff will provide the resident with human physical help with these activities of daily living.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A
Complaint related:	No
Description:	Based on observation the facility failed to ensure that the medication storage area was locked. Evidence: On 12/27/2023 at approximately 12:09p.m the medication cart on the Dogwood unit was observed to be unlocked. There was no staff near the cart and residents were in the area where the unlocked cart was being stored. The facility medication aide assigned to the Dogwood unit stated that she had to step away for a minute to blow her nose.
Plan of Correction:	Not available online. Contact Inspector for more information.