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: March 3, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

22VAC 40-73-450 - Individualized service plans When individualized service plans are updated and/or goals are added, deleted, modified by staff, the date of the addition, deletion, modification is recommended.

Comments:

An unannounced monitoring inspection was conducted at the facility on 3/3/2020 by two licensing inspectors between 10:30 am and 4:00 pm to follow-up on a self reported incident. An anonymous complaint was also received in regards to the incident. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice 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 with the standard, 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). See violation notice for non-compliance

Violations:

Standard #:	22VAC40-73-210-G
Description:	Based on a review of the training attendance form dated 2/11/2020, staff training on safe transfers did not include documentation of the entity that provided the training or the number of hours of the training. Evidence: As evidenced by a copy of the 2/11/2020 training attendance form provided to licensing staff, the training form did not have the name of the instructor or the hours of training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-300-B
Description:	Based on a review of shift reports for 2/10/2020 and 2/11/2020 by two licensing staff, the facility failed to maintain a method of written communication as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental condition. Evidence: 1. Resident # 1 was seen in the local ER (emergency room) on 2/11/2020 for injuries and a reported assault. 2. Licensing staff requested nurses notes for resident # 1 for the dates of 2/10/2020 and 2/11/2020. 3. Shift reports were provided for 2/10/2020 and 2/11/2020. 4. There was no documentation of the injuries or ER visit in the staff shift reports.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-E
Description:	Based on a review of a resident's file on 3/3/2020, the facility failed to regularly observe and document in the resident's file any notable changes in the resident's condition or functioning, including illness, injury or altered behavior. Evidence: 1.Two licensing staff conducted an inspection at the facility on 3/3/2020 to follow-up on a self reported incident of a reported possible assault of resident # 1 on 2/11/2020. 2. An anonymous report was also received that resident # 1 was found on 2/11/2020 with bruising to the chest and vaginal area and swelling to the left shoulder. 3. Resident # 1 was seen in the local ER (emergency room) on 2/11/2020 as evidenced by a discharge report dated 2/11/2020. 4. A review of the file for resident # 1 found no documentation of facility staff observation of any injuries on or prior to 2/11/2020.
Plan of Correction:	Not available online. Contact Inspector for more information.