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. 18, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 9-18-2023, 9:55 ? 10:40 am 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 8-25-2023 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 90 Observations by licensing inspector: Tour of memory care unit. 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1160-A
Description:	Based on observation and interview with staff, the facility failed to ensure there was a secured outdoor area for residents or provide direct care staff supervision while residents are outside. Evidence: The courtyard was observed in the safe, secure environment (SSE) on 9-18-2023 was reported to have a magnetic locking device on it that wasn?t working at the time of the elopement. Staff #1 reported that it was fixed same date and was observed to be working on that date.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was completed at least annually. Evidence: Resident #1?s record contained a UAI dated 12-22-2021, and no other UAI was located in the record. Staff #1 confirmed during interview that Resident #1?s UAI was not completed at least annually.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were updated at least once every 12 months. Evidence: Resident #1 admitted 12-22-2021. Resident #1?s ISP dated 12-22-2021 was the only one located in the record. Staff #1 confirmed Resident #1?s ISP was not updated at least once every 12 months.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to ensure attention to specialized needs, such as wandering from the premises. Evidence: Resident #1 admitted 12-22-2021. Resident #1?s uniform assessment instrument dated 12-22-2021 documented under ?Behaviors?, ?Wandering, weekly or more.? An elopement timeline provided by Staff #1 documented that on 8-19-2023, Resident #1 was noticed missing from the dining room at approximately 12:45 p.m. by staff. The timeline documented that police arrived at the facility at 1:35 p.m. to notify that Resident #1 had been located and was on the way back to the facility. Staff #1 confirmed during verbal interview that the resident had gotten down a ?five minute walk? by Three Chopt Road (approximately 1 ? miles from the facility). The road the facility is located on has four lanes (two each direction), has a 45 mile per hour speed limit, and no sidewalks. It was determined through the facility?s investigation that the security system securing the back gate malfunctioned, per Staff #1.
Plan of Correction:	Not available online. Contact Inspector for more information.