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: April 26, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-26-24 from 10:02 a.m.-1:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1-22-24 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 99 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-430-H-2
Complaint related:	No
Description:	Based on a review of the resident?s record the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record. Evidence: The record for Resident # 1 (discharge date: 3-21-23) did not contain a discharge statement.
Plan of Correction:	1. Immediate correction was made. 2. Director of wellness and the business office director educated. 3. A discharge statement will be issued for each move-out. 4. Monthly discharge statement audits will be initiated by director of wellness or designee. 5. Findings and corrections will be discussed during the monthly QA meeting.
Standard #:	22VAC40-73-650-E
Complaint related:	No
Description:	Based on a review of the resident?s record the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders shall be organized chronologically in the resident's record. Evidence: The record for Resident # 1 did not contain a signed physician?s order for insulin. However, the resident?s Discharge Medications List dated 2-27-23 from Henrico Doctors Hospital listed ?Insulin Lispro- Three Times Daily Before Meals.?
Plan of Correction:	1. Community will monitor all physician's or other prescriber's signed written orders maintained. 2. in residents? charts. 3. An Inservice regarding written orders will be provided to the director of wellness/ charge nurses, and MedTech?s. 4. All charts will be audited, and orders will be organized chronically in the residents' records. 5. Quarterly audits will be initiated to ensure all orders are in place. 6. Findings and corrections will be reviewed during the next QA meeting.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of the resident?s record the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber?s instructions. Evidence: The record for Resident # 1 contained a Discharge Medications List dated 2-27-23 from Henrico Doctors Hospital listed ?Insulin Lispro- Three Times Daily Before Meals.? However, the facility?s ?Order Administration Tracking? documentation indicated that Insulin was not administered to the resident until 3-17-23 at 8:00 a.m. and12:00 p.m., 3-18-23 at 12:00 p.m. and 4:00 p.m., and 3-20-23 at 8:00 a.m.
Plan of Correction:	1. Community will ensure all prescribed medications are administered as ordered. 2. An Inservice will be provided to all nurses and MedTech's. 3. All charts will be audited, and orders will be organized chronically in the residents' records. 4. Quarterly audits will be initiated to ensure all orders are in place. 5. Findings and corrections will be reviewed during the next QA meeting.