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: Dec. 13, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Inability to utilize signaling device to be included in ISP. Prior to admission resident interview should be documented.

Comments:

An unannounced monitoring inspection was conducted by two Licensing Inspectors from the Eastern Regional Office on 12-13-2021 from 8:21AM to 1:43 PM. There were 57 residents in care at the time of the inspection. A tour of the facility was conducted, water temperatures were sampled, resident?s rooms observed, and two activities were observed. A medication pass observation was completed with 3 staff and 5 residents. 5 staff records and 6 resident records were reviewed. LI reviewed: a first aid kit, fire and resident emergency drills, dietary and health care oversights, and the emergency food and water supply. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on documentation review and interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident is assessed by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The Assessment of Serious Cognitive Impairment form dated 10-08-2020 for Resident #3 asked if the individual named above is unable to recognize danger or protect his/her own safety and welfare. This question was left blank. 2. Staff #2 and Staff #3 acknowledged Resident #3?s Assessment of Serious Cognitive Impairment did not indicate whether the resident was unable to recognize danger or protect his/her own safety and welfare.
Plan of Correction:	1. On 12/14/21, clarification completed by Nurse Practitioner indicating resident #3 is unable to recognize danger or protect his/her own safety and welfare. 2. All admission documents will be audited prior to admission by Executive Director, Memory Care Advisor and Resident Services Director.
Standard #:	22VAC40-73-260-A
Description:	Based on documentation review and interview, the facility failed to ensure each direct care staff member maintain a current certification in first aid. Evidence: 1. Staff #10 (hired on 06-22-2021 as a CNA) did not have a current certification in first aid. 2. Staff #4 acknowledged there is not documentation of a current certification in first aid for Staff #10.
Plan of Correction:	1. Staff member #10 is no longer employed by Arden Courts of Virginia Beach. Last day of employment was 10-6-21.
Standard #:	22VAC40-73-310-H
Description:	Based on documentation review and interview, the facility failed to ensure an individual was not admitted with a prohibited condition as stated in the Code of Virginia. Evidence: 1. Resident #1?s admitting physical examination report completed 11-17-2021 documented that the resident requires continuous licensed nursing care. 2. Resident #5?s physical examination report had both areas regarding ambulation (ambulatory and nonambulatory) checked. Ambulation status could not be determined. 3. Staff #2 and Staff #3 acknowledged the aforementioned information regarding Resident #1 and Resident #5?s physical examinations.
Plan of Correction:	1. On 12/20/21, received corrected documentation from medical doctor stating resident does not require continuous nursing care. 2. On 12/13/21, clarification regarding ambulation status was corrected to non-ambulatory status. 3. All admission documents will be audited prior to admission by Executive Director, Memory Care Advisor and Resident Services Director.
Standard #:	22VAC40-73-325-B
Description:	Based on documentation review and interview, the facility failed to ensure the fall risk rating be reviewed and updated at least annually. Evidence: 1. The most recent fall risk rating for Resident #3 was 12-02-2019. Additionally, the most recent fall risk rating for Resident #4 was 10-09-2020. 2. Staff #2 acknowledged the aforementioned fall risk ratings for Resident #3 and Resident #4 were the most recent.
Plan of Correction:	1. On 12/13/21, Staff # 3, completed a fall risk assessment for Resident #3 and Resident #4. Staff member #2 and # 3 will ensure annual fall risk assessments on all residents. 2. An audit will be conducted by the Resident Services Director or designee by January 15th and annually moving forward to maintain compliance.
Standard #:	22VAC40-73-440-L
Description:	Based on documentation review and interview, the facility failed to maintain the completed UAI in the resident?s record. Evidence: 1. Resident #3?s UAI dated 10-09-2021 and Resident #4?s UAI dated 10-01-2021 were not signed by the administrator or designee. 2. Staff #2 and Staff #3 acknowledged the UAI for Resident #3 and Resident #4 were not signed for approval by the administrator or designee.
Plan of Correction:	1. On 12/13/21, both UAI?s for resident #3 and 4 were signed by designee. 2. ED, Resident Services Coordinator and designee will audit UAI?s and ISP?s semi-annually as scheduled.
Standard #:	22VAC40-73-450-C
Description:	Based on documentation review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. Resident #1?s UAI dated 11-30-2021 documented the need of physical assistance with dressing; however, the resident?s ISP states resident needs ?dressing supervision.? 2. Resident #2?s UAI dated 11-10-2021 documented the need of physical assistance with dressing; however, the resident?s ISP states resident needs ?dressing supervision.? Additionally, Resident #2?s UAL documents incontinence less than weekly for both bowel and bladder; however, the resident?s ISP did not include documentation of the need. 3. Resident #5?s UAI dated 08-10-2021 documented the resident had a need of assistance for walking; however, the resident?s ISP did not include documentation of the need. 4. Staff #2 and Staff #3 the aforementioned ISPs did not include a description of the resident?s identified needs based on the UAI.
Plan of Correction:	1. New UAI for resident #1 was completed on 12/14/21 to correctly indicate residents level of care to match the ISP. 2. On 12/14/21, resident #2, UAI was corrected to match ISP and reflect residents current level of care and bowel and bladder incontinence. 3. On 12/14/21, Resident #5, UAI was corrected to match the residents ISP that correctly indicates no need for assistance with walking. 4. ED, Resident Services Coordinator and designee will audit UAI?s and ISP?s semi-annually as scheduled.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and interview, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. During the tour of the facility with Staff #5, a meal menu for 12-13-2021 was observed posted outside the kitchen adjacent to a resident common area. It was also noted that a breakfast menu was not posted in one of the neighborhood?s dining areas. 2. Staff #5 acknowledged the meals for the current week were not posted.
Plan of Correction:	1. On 12/14/21, weekly menus were completed and placed on each neighborhood for resident and family viewing. Also, breakfast meal was added to the already posted lunch and dinner menu. The breakfast menu was posted on the kitchen door as you enter into the Town Center.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the building was kept clean. Evidence: 1. During a tour of the Ocean Sands neighborhood with Staff #3, the light fixture in the ceiling near room 303 was observed to have grey colored substance on the vents of the light cover. Staff #3 called Staff #6 over to the area to view the lighting cover. 2. Staff #6 stated the grey substance on the light covering was lint that was coming from the dryer. 3. Staff #3 and Staff #6 acknowledged the grey colored substance on the vents of the light cover.
Plan of Correction:	1. On 12/13/21, staff member #6 cleaned the only vent that had a light dusting of grey colored substance that was lint. 2. Vents will be cleaned and filters will be replaced quarterly and as needed.