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: Aug. 15, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED 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: 8-15-2023, 9:26 ? 9:39 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 6-27-2023 regarding allegations in the area of Resident Care and Related Services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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 Alex 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, the facility failed to ensure the licensee complied with the facility's own policies and procedures. Evidence: 1. The facility?s ?Elopement Risk? policy revised 4-2022 defines elopement as, ?Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so?. 2. Resident #1 admitted on 5-26-2022 to the safe, secure environment (SSE). Based on Resident #1?s Progress Notes, Resident #1 was able to exit the SSE of the building on three occasions: 6-20-2023 and 7-26-2023. 3. The facility?s ?Elopement Risk? further documents, ?"The community shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary..." Staff #1 was asked what interventions these were prior to 7-26-2023 incident to which Staff #1 emailed [in summary] that the back gate had been left open by lawnscaping team, and the landscaping team were trained to secure gate behind them, memory care staff is to direct residents away from lawnscaping while happening, and the maintenance director is to ensure gate is locked and secured.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Description:	Based on record review, 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 #1?s Progress Notes documented the following incidents that were not reported to the regional licensing office: A. 8-31-2022: ??[Resident #1] attack resident in room 149 on his neck and shoulder asking resident in room 149 to repeat what he said to him. Writer called for help while trying to separate them?? B. 1-30-2023: ??[Resident #1] and another resident [room 151] were seen in his room lying in bed with [other resident] hands in [Resident #1] pants?? C. 4-29-2023: ??witnessed pushing another resident for trying to enter [Resident #1?s] apartment?? D. 6-09-2023: ??witnessed [Resident #1] pushing another resident?? 2. None of the previously mentioned incidents involving Resident #1 were sent to the licensing office.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure all residents were assessed using the uniform assessment instrument (UAI) at least annually. Evidence: Resident #1 admitted 5-26-2022. The only UAI in Resident #1?s record was dated at admission, 5-26-2022.No other UAI was in Resident #1?s record during inspection on 8-15-2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure individualized service plans (ISPs) were reviewed updated at least once every 12 months. Evidence: Resident #1 admitted 5-26-2022. The only UAI in Resident #1?s record was dated at admission, 5-26-2022. No other ISP was located in the resident?s record during inspection on 8-15-2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-D
Description:	Based on record review, the facility failed to provide supervision of resident care including attention to specialized needs such as wandering from the premises. Evidence: 1. Progress Notes dated 7-26-2023 documented, ?Resident [#1] found outside with no staff present. No injuries. Resident [#1] stated he wanted to get out of here. Family notified via telephone. MD notified via telephone. Due to the statement made we suggested moving the resident on the 2nd floor for his safety?? 2. Upon interview and tour of the memory care courtyard, Staff #1 accompanied the licensing inspector and showed where the resident had removed mechanisms on the door and been able to leave the machinery where the magnetic lock was (that did not work properly). Staff #1 confirmed that Resident #1 was able to walk down Gaskins Road (that has no sidewalks, with a speed limit of 45 miles per hour). The exact amount of time report unaccounted was approximately five minutes, per email and interview with Staff #1.
Plan of Correction:	Not available online. Contact Inspector for more information.