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 9, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: March 9, 2023; 9:20 a.m. ? 10:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on December 7, 2022 and December 30, 2022 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 92 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law was: Administration and Administrative Services. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-40-A
Description:	Based on record review and interview with staff, the licensee failed to ensure compliance with the facilities own policies and procedures. Evidence: 1. The facility?s policy titled, ?Abuse, Neglect or Exploitation Prevention? revised 10/2019 documented the definition of abuse as: ?The willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish of a vulnerable adult. Abuse includes neglect, verbal, sexual, mental, physical and exploitation of a vulnerable adult.? 2. Additionally, the aforementioned policy documented, ?Protecting the Resident from Further Harm: a. Report the event to the Leader on Duty so a plan can be developed to protect the resident from further harm.? 3. The first incident report received regarding Resident #1 dated 12-06-2022 documented, ?Resident [#1] stated two staff members gave her a shower after she refused. Resident [#1] stated, " I didn't want to take a shower, I said no I'm scared to fall, they made me it was two of them, look at my arm". noted bruising to left arm and skin tear to left elbow 0.1cm and left upper arm 0.3cm?? 4. A second incident report received regarding Resident #1 dated 12-30-2022 documented, ?[Resident #1] made the charge nurse aware care staff last night was rough while putting [Resident #1] to bed. Statements were collected by and skin assessment done skin intact no bruises and scratches noted, and POA was called. Resident [#1] is HOH [hard of hearing] and has vision issue. PCA [personal care aide] stated [PCA] was coming out of bathroom with walker to assist resident [#1] to bed noted resident [#1] standing up about to fall because wheelchair petals were still out in front of legs [PCA] rushed over to break fall turned and pivot resident [#1] on bed finished assisting resident in bed?? 5. There was no plan developed to protect the resident from further harm between the 12-06-2022 documented incident of a ?refused shower? reported by Resident #1, and ?rough handling? by staff on 12-29-2022.
Plan of Correction:	Current staff will receive re-education on Resident?s Rights / Abuse & Neglect reporting. This will be completed on or before June 9, 2023. This will be the responsibility of the Administrator or designee. New hire staff during orientation will receive Resident Rights, Abuse & Neglect reporting .
Standard #:	22VAC40-73-40-B-5
Description:	Based on record review and interview with staff, the licensee failed to protect the physical and mental well-being of residents. Evidence: 1. Resident #1 admitted 9-07-2022. Resident #1?s uniform assessment instrument dated 9-06-2022 documented under bathing, ?mechanical and human help, physical assistance?. Resident #1?s Progress Notes documented on 12-06-2022, ?At 10am resident [#1] physical therapy [sic] stated, ?resident [#1] was visibly upset she said staff gave a shower after she refused and they were rough? Resident [#1] saw writer [Staff #1] and stated I [Resident #1] didn?t want to take a shower, i told them I knew my rights but they did it anyway?I didn?t want to take a shower, I said no I?m scared to fall, they made me it was two of them, I screamed no, look at my arm??. 2. Additionally, Resident #1?s Progress Notes documented on 12-30-2022 documented, ??resident [#1] c/o [complained of] caregiver being rough last night? writer [Staff #1] interviewed resident [#1] with [Staff #2] present ?Last night like usually after dinner I go to bed, the lady sated [sic] give me a minute or two I will be back? I [resident #1] got up by myself in wheelchair, I was near the bed and then she rushed over pushed me on the bed it was rough? Writer [Staff #1] asked resident [#1] was anything hurting resident stated ?my back?, resident pointed to lower back noted pain patch in place? skin assessment scratches noted?? 3. Staff #1 acknowledged both self-reported incidents by Resident #1 and that the aforementioned incidents took place.
Plan of Correction:	Staff will receive re-education on Resident?s Rights /Abuse & Neglect reporting. This will be completed on or before June 9, 2023. This will be the responsibility of the Administrator or designee. New hire staff during orientation will receive Resident Rights, Abuse & Neglect reporting