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. 28, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS X 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES X 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION X 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS X 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS X 22VAC40-73 BUILDINGS AND GROUND X 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

Specifying all applicable areas of Discharge Notification and Statement

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9-28-2022, 9:00 a.m. ? 1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 88 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: meals, medications, activities, tour, records An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on record review and interview with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident #2?s Progress Notes documented the following fall on 6/15/2022, 2:54 a.m. ?At 11:35pm of 6/14/22, Care staff called for nurse? Resident [#2] had called, found on floor face down? Hematoma noted on left side of forehead, small skin tear noted on left cheek and swollen lips. Resident was sent out via 911 to St. Mary?s Hospital for evaluation? Dx: Fall; Acute post-traumatic headache not intractable??; however, no incident report was received by the the regional licensing office within 24 hours.
Plan of Correction:	Staff training on Mandated Reporters and Incident Reporting that could affect the safety and welfare of the affected resident, will be completed during the month of November and will be completed by the end of the month, ensuring that staff have received the training as required by the Department of Social Services.
Standard #:	22VAC40-73-130-A
Description:	Based on record review, the facility failed to ensure all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. Evidence: 1. Resident #3?s ?Progress Note? by the physician dated 6-23-2022 documented, ??States that her back always hurts now. Also claims that she was pushed by a staff member??; however, no documentation that local social services was notified was seen.
Plan of Correction:	Staff training on Mandated Reporters and Incident Reporting that could affect the safety and welfare of the affected resident, will be completed during the month of November and will be completed by the end of the month, ensuring that staff have received this training as required
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that the physical examination for a resident contained the description of the person?s reactions to known allergies. Evidence: 1. Resident #5 admitted 12-22-2021. Resident #5?s ?Report of Resident Physical Examination? dated 12-01-2021 documented allergies to Sulfa, Zocor, Iodine, Morphine, Naproxen, Barbiturates, and Erycin; however, there were not reactions listed for the allergies. 2. Resident #8 admitted 9-20-2022. Resident #8?s ?Report of Resident Physical Examination? dated 9-19-2022 documented allergies to Peanuts and Isoniazid; however, there were no reactions listed for the allergies.
Plan of Correction:	Violations have been corrected. The DOW or designee will review H and P?s and Physician Orders/Notes for allergies and request, if not noted, what the reaction was to the allergen. Allergies and Reactions will be noted on the ISP?s. If reaction is unknown by the provider, that will be noted as well. ED or Designee will randomly audit eHR system for allergies to ensure compliance.
Standard #:	22VAC40-73-410-A
Description:	Based on record review and interview with staff, the facility failed to provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: 1. Resident #3 (date of admission 10-29-2021), Resident #5 (date of admission 12-22-2021), and Resident #8?s (date of admission 9-20-2022) records did not contain copies of orientation in the record. 2. Staff #1 acknowledged these items were not in the residents? records during inspection.
Plan of Correction:	This violation will be completed by December 15 after a audit of all resident files. Any resident that has not completed orientation will have an in depth orientation. A policy will be put in place to ensure Orientation will be completed on all new residents within the first 7 days.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan included a description of identified needs and date identified based upon the UAI, admission physical examination, and other sources. Evidence: 1. Resident #1 admitted 3-20-2020. Resident #1?s Uniform Assessment Instrument (UAI) dated 3-15-2022 documented the resident requires mechanical help and human help, physical assistance with bathing; however, Resident #1?s ISP dated 3-15-2022 did not include mechanical help under bathing assistance. Additionally, Resident #1?s UAI documented mechanical help and human help, physical assistance of two staff with transferring; however, the resident?s ISP did not include mechanical help under transferring. 2. Resident #2 admitted 1-14-2020. Resident #2?s UAI dated 7-5-2022 documented the resident requires human help, physical assistance with bathing; however, Resident #2?s ISP dated 7-15-2022 documented the resident requires mechanical help and human help, physical assistance with bathing. The resident?s UAI documented the resident receives no help with toileting; however the ISP documented the resident uses mechanical help with toileting. 3. Resident #4 admitted 7-31-2021. Resident #4?s UAI dated 8-19-2022 documented mechanical help and human help, physical assistance for dressing; however, Resident #4?s ISP dated 8-07-2022 documented human help, physical assistance with dressing. Additionally, the resident?s UAI documented, ?performed by others? under stairclimbing assistance; however the ISP documented mechanical and human help, physical assistance with stairclimbing. 4. Resident #6 admitted 4-18-2021. Resident #6?s UAI dated 4-18-2022 documented mechanical help with bathing; however, the resident?s ISP dated 4-18-2022 did not document assistance with bathing. Additionally, the UAI documented using rails under stairclimbing assistance; however, stairclimbing was not identified on the ISP. Lastly, the resident?s UAI documented the resident requires assistance by professional nursing staff for medication administration; however, the ISP documented the resident self-administers medication (based upon the physician?s order to self-administer on 4-18-2021 and review of self-administration completed quarterly by the facility). 5. Resident #7 admitted 7-23-2018. Resident #7?s UAI dated 11-04-2021 documented mechanical and human help, physical assistance with bathing; however, the resident?s ISP dated 11-08-2021 did not address mechanical help with bathing. Additionally, the UAI documented mechanical and human help, supervision with dressing, toileting, and transferring; however, the ISP did not contain mechanical help for any of those identified needs. Resident #7?s UAI documented the resident wanders; however, the ISP does not identify wandering. 6. Resident #9 admitted 6-21-2022. Resident #9?s UAI dated 9-21-2022 documented human help, physical assistance with toileting; however, the resident?s ISP dated 9-24-2022 documented ?independent? for toileting.
Plan of Correction:	Noted Violations have been corrected on UAI?s and ISP?s. The DOW will be re-educated by the ED by 11/10/22 on the expectation that the UAI and the ISP mirror each other and the resident?s needs. For UAI and ISP compliance, the ED or Designee will review and sign both documents signifying that the documents match and are noting the correct care that is to be provided to the residents. Family/POA reviews of ISP?s will be scheduled for review to ensure the accuracy of the care needs of the resident.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview with staff, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. During tour of the facility, the following was observed: a. Three white ceiling tiles were stained a light brown in the corners as well with four semi-circle shaped spots on the first floor in the special care unit (SCU); and b. The carpet on the third floor of the assisted living located by the wellness center and laundry had black circular stains in a line pattern across the carpet in three areas. 2. Photographic evidence was obtained of the aforementioned areas and Staff #1 observed during the tour.
Plan of Correction:	Preventative Maintenance Plan will be put in place to include general carpet cleaning and general maintenance. This plan will include bi-weekly carpet cleaning or as needed prior to scheduled cleaning to remove any stains and to preserve carpet. General Maintenance plan will be in place on areas of the community and outside of community to ensure that building is clean and neat in appearance at all times. The ED or Designee will monitor for compliance by doing community walk thrus on a random basis.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. There was no fire and emergency evacuation drill recorded for the month of April 2022. 2. Staff #1 acknowledged during interview that there was no monthly recorded April 2022 drill.
Plan of Correction:	Emergency drills will be completed every 6 months on rotating shifts and emergency Fire Drills will be completed monthly on rotating shifts. Both types of drills will be documented and kept on file in the Maintenance Director?s office and ED office.