VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Richmond)
13800 Bon Secours Drive
Midlothian, VA 23114
(804) 378-5100

Current Inspector: Tyia Venable (804) 393-2157

Inspection Date: May 10, 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 05/10/2024- approximate time of 10:48 a.m-2:07p.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 04/23/2024 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 49 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: N/A Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: A walk through of the interior of the facility was conducted 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 #:	22VAC40-73-530-C
Complaint related:	No
Description:	Based on observation and interviews conducted the facility failed to ensure that they provided freedom of movement for the residents to their personal spaces. Facility staff shall not lock residents out of or inside their rooms. Evidence: During a walk-through of the Cardinal and Monument units of the facility on 05/10/2024 with facility staff the following was observed. Cardinal unit: Resident bedroom # 102 on the Cardinal neighborhood was found to be locked. During subsequent interviews, facility staff stated that the family requested the resident?s room is locked because other residents often wander into the room. Monument unit: Resident bedroom #s 402, 404, 407 and 410 were also found to be locked. During interviews facility staff stated that the bedroom doors are locked because some of the incontinent residents from other facility units wander into the Monument unit and lay in other resident beds and cause the rooms to become unclean. During the 05/15/2024 telephone interview facility staff also confirmed that the bedroom doors on this unit were in fact locked because incontinent residents wander from other units and causes the rooms to become unclean
Plan of Correction:	FACILITY'S RESPONSE: "The facility will remove exterior locks on needed resident?s bedroom doors."
Standard #:	22VAC40-73-860-I
Complaint related:	No
Description:	Based on observation on 05/10/2024 the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. Evidence: The inspector observed the following during a walk-through of the Capital unit on 05/10/2024. Four spray bottles were observed in an unlocked closet in the hallway across from room #310. The label on 2 of the spray bottles read glass cleaner. The label on 1 spray bottle read 73 Disinfecting Acid Bathroom Cleaner. The label on 1 spray bottle read Bio-Enzymatic Odor Eliminator. Photos were taken on this date of the unlocked chemicals.
Plan of Correction:	FACILITY'S RESPONSE: "The facility shall store all cleaning supplies and other hazardous materials in a locked area."