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. 6, 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 12/06/2023 Approximate time 9:36a.m-2:41p.m. On 12/19/2023 Approximate time 9:01a.m-4:10p.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 10/31/2023 regarding allegations in the areas of staffing and supervision, resident care and related services and Article 3 caring for residents with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 44 On 12/06/2023 the resident census was 43. On 12/19/2023 the resident census was 44. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 7 Observations by licensing inspector: Lunch time meals observed and the dietary department. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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 #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on staff interviews conducted and observation the facility failed to any absences, substitutions, or other changes to the work schedule is noted on the schedule. Evidence: Facility staff #2 The facility?s Caregiver Assignment document charting for 12/06/2023 noted that facility staff #2 was assigned to the Capital unit of the facility. Based on observation and staff interviews conducted that included the facility Administrator it was revealed that facility staff #2 was not onsite at the facility during the 7-3 shift as noted on the Caregiver Assignment document. The facility did not update the 12/06/2023 staff assignment schedule to note the absence of facility staff #2.
Plan of Correction:	FACILITY'S RESPONSE: "The caregiver assignment sheets will be updated by RSC/designee when call outs occur."
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that a reassessment due to a significant change in the resident's condition, using the UAI, is utilized 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 #2 Facility staff documented on the resident?s 09/25/2023 fall risk evaluation form that the resident has combative behaviors. The resident?s 09/29/2023 ISP note a goal as ?Provide opportunities to minimize potential socially inappropriate or intrusive behaviors. Upon request to review the most recent UAI conducted for the resident facility staff submitted the 09/29/2023 UAI that does not identify the resident as having abusive or aggressive behaviors
Plan of Correction:	FACILITY RESPONSE: "Facility UAIs will be reviewed and updated if residents have a change of condition with aggression."
Standard #:	22VAC40-73-450-H
Complaint related:	No
Description:	Based on observation and record review, the facility failed to ensure that care and services specified in the individualized service plan (ISP) are provided to each resident. Evidence: Resident #1- The resident?s February 2023 ISP notes that the resident ?requires human help physical assistance for dining and eating daily.? The facility reassessed the resident on 03/01/2023 as needing physical assistance human help with feeding. During the lunch time meals on 12/06, 19/2023 the inspector observed the resident feeding herself with no human help from facility staff. When the inspector asked why she was not provided assistance facility staff stated that she just takes a long time to eat and that it takes her ?45 minutes to eat?.
Plan of Correction:	FACILITY'S RESPONSE: "Nursing staff will be educated on residents that need assistance with eating. An updated list of residents who need feeding assistance will be developed based on ISP goals."