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: July 27, 2021 , July 29, 2021 and July 30, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report monitoring inspection was initiated on July 27, 2021 and concluded on August 3, 2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on July 30, 2021. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to provide attention to specialized needs such as wandering from the premises. Evidence: 1. Resident #1 admitted 6-18-2021 to the facility?s Safe Secure Environment (SSE). A self-reported incident received by the Central Licensing Office on 6-28-2021 documented the following occurred on 6-26-21 at 3:00 p.m., ?Resident [#1] left the memory care neighborhood via the back gate and was retrieved by a team member.? 2. Resident #1?s Progress Notes dated 6-26-2021 at 6:05 p.m. documented, ?Resident [#1] left the building this afternoon through the back door (which was open), one of the staff who was heading to Kroger saw her in the packing lot and brought her back to the building?? 3. Staff #1 and Staff #2 stated that the back gate in the SSE was unlocked as repair workers were entering and exiting the facility through the gate. The facility did not provide supervision of residents to ensure no one exited the unlocked gate. 4. Staff #1 and Staff #2 confirmed during interview that Resident #1 had gotten out through the back gate that enters the SSE, and was retrieved on the sidewalk in front of the facility at Gaskins Road, where the speed limit is 45 miles per hour.
Plan of Correction:	Based on the Executive Director?s review of the incident, the community proactively took the following steps: 1. Emergency exit gate at the rear of the Memory Care garden was professionally inspected by an outside company to ensure that the gate was in good condition and not malfunctioning 2. All staff was in serviced on elopement and new resident protocols. Drills were also conducted to ensure that the staff responded in accordance to the training. 3. Chirping alarms were installed on the doors that lead to the secure backyard as an extra layer of safety. These alarms alert staff as to when a resident has entered the secured backyard independently. 4. Upon investigation the team who was on site at time of elopement did respond in the appropriate manner according to our Missing Person protocols. No corrective action was necessary with staff members.