VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vitality Living West End Richmond
1800 Gaskins Road
Henrico, VA 23238
(804) 741-8880

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Sept. 12, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced renewal inspection was initiated at the facility by two licensing inspectors on 9/12/2019 from approximately 8:45 am to 1:00 pm and was concluded on 9/20/2019. The facility staff reported 92 residents in care, ten resident and five staff files were reviewed for compliance. Licensing staff also reviewed required program information, interviewed residents and staff, observed medication passes and inspected the physical plant for compliance. See violation notice for non-compliances.Please complete the "plan of correction" and "date to be corrected" for the violations cited and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance, 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on a review of nine resident files by two licensing representatives on 9/12/2019, the fall risk rating for two residents was not updated and reviewed after a resident fall. Evidencce: 1. The review of the file for resident # 8 documented falls on 7/31/2019 and 8/26/2019. Licensing representatives and facility staff (Health and Wellness Director and Clinical Coordinator) searched the file and did not find a fall risk rating that was completed after the two falls. 2. The resident log for resident # 4 documented a fall on 9/6/2019 and a fall followup on 9/9/2019. Licensing representatives and facility staff (Health and Wellness Director) searched the file and did not find a fall risk rating that was completed after the fall. The Health and Wellness Director stated to licensing representatives that the log entry note from 9/6/2019 was entered by mistake.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-410-A
Description:	Based on a review of nine resident files on 9/12/2019, one resident did not receive orientation upon admission that included emergency response procedures, mealtimes, and use of the call system. Evidence: Acknowledgment of having received the orientation was not found for resident # 1 during the file review by two licensing representatives.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Description:	Based on a review of nine resident files by two licensing representatives, the uniform assessment instrument (UAI) for one resident was not updated after a change in the resident's condition. Evidence: The individualized service plan (ISP) for resident # 1 dated 5/31/2019 documented that the resident is independent in dressing and toileting. The ISP was updated on 7/2/2019 to state that the resident "has periods of incontinence, needs help to change" and "need queing to go change/let staff help her change due to incontience". The resident's UAI was not updated to reflect these changes in condition. The UAI is dated 5/31/2019 and documents that the resident does not need help in dressing and toileting.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of ten resident files by two licensing representatives on 9/12/2019, the individualized service plan (ISP) for one resident does not describe services to be provided to address identified needs. Evidence: The section of the ISP for resident # 2 that documents services to be provided documents the identified need instead. i.e. "(resident name) is incontinent of bowels" ,(resident name) is dependent with ambulation", (resident name) is incontinent of bladder".
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on a random inspection of the interior of the building by two licensing inspectors on 9/12/2019, the interior of the building is not being kept clean. Evidence: 1. A door in Claridge was soiled with dirt. 2. The carpet in the hallway of Claridge was soiled with dirt and stains. 3. A hallway wall in Claridge was soiled with dirt. 4. A chair in the common area near the dining room on the 1st floor was soiled and stained. 5. Cobwebs and dirt was on the baseboards and railings in the first floor common area. 6. A door leading to an outside area on the first floor was soiled with dirt. 7. The carpet on the third floor was stained.
Plan of Correction:	Not available online. Contact Inspector for more information.