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: Oct. 13, 2023 and Oct. 30, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview with staff, the facility failed to ensure health information maintained at the facility included an initial tuberculosis examination or an annual subsequent tuberculosis evaluation. Evidence: Staff #2?s date of hire was 3-31-2021. Staff #2?s record did not contain an initial or subsequent tuberculosis record. Staff #1 confirmed onsite that the file did not contain the tuberculosis evaluation(s) for Staff #2.
Plan of Correction:	1- Records reviewed. 2- Community will ensure new staff will have tuberculosis examination prior to the start date and annually. 3- Business office director will be educated on the company and the State expectations. 4- Finding will be reviewed during the next QA meeting.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure the person?s physical examination identified a description of the person?s reaction to any known allergies. Evidence: Resident #5 admitted 2-27-2023. Resident #5?s Report of Resident Physical Examination dated 1-31-2023 documented ?Quinidine, Sulfate Salt? as allergies; however, no reactions to the allergies were documented.
Plan of Correction:	1- Resident records reviewed. 2- Community will ensure notifications regarding persons' reactions to any known allergies to PCP. 3- Resident care coordinator and director of wellness will be educated in keeping record on allergic reaction and communication. 4- Director of wellness/designee will completed random resident chart audits and communicate with the primary providers for corrections/updates of the residents' records. 5- Finding will be reviewed during the next QA meeting.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure the fall risk rating shall be reviewed and updated when the condition of the resident changes and after a fall. Evidence: 1. Resident #5 admitted 2-27-2023. Resident #5?s Nurses Notes documented the following on 9-03-2023: ?At 6:30 this am this nurse heard someone yelling help. Upon entering room resident noted to be on the floor beside his bed. Checked for injuries. None noted. Vital signs stable. Staff assisted resident into his wheelchair. Stated he slid out of his wheelchair.? 2. Additionally, an incident report dated 9-10-2023 received by the licensing office documented the following, ?Date of Incident: 9/10/2023? Description of the Incident: On 9/11/2023 Mr. Stendahl called the facility from the hospital and explained that he sustained a broken neck from a fall the day before. He explained that he bent down to pick up a pen, fell forward out of his wheelchair hit his head on the wall of his apartment?? 3. Neither the 9-3-2023 nor the 9-10-2023 fall had Fall Risk Ratings documented in Resident #5?s record.
Plan of Correction:	1- Resident record reviewed. 2- Community will complete fall risk rating with change of resident condition, after a fall, return from a hospital stay. 3- Resident care coordinator and director of wellness will be educated on fall risk rating. 4- Director of wellness/designee will complete a random resident chart audits monthly of fall risk. 5- Finding will be reviewed during the next QA meeting.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. The following resident ISPs were not updated to reflect needs of the resident: A. Resident #1 admitted 9-08-2021. Resident #1?s current ISP dated 9-06-2023 did not identify money management as a service need (as identified on Resident #1?s Uniform Assessment Instrument (UAI) dated 9-06-2023). Additionally, Resident #1?s personal/social data documented a Penicillin allergy that was not on the ISP. B. Resident #2 admitted 4-18-2021. Resident #2?s current ISP dated 6-15-2023 did not identify money management as a service need (as identified on Resident #2?s UAI dated 6-15-2023). Additionally, the UAI documented ?mechanical help, handrails? with stairclimbing was not on the ISP, and the personal/social data documented an Amoxicillin and Benadryl allergy that was not addressed on the ISP. C. Resident #3 admitted 8-20-2022. Resident #3?s current ISP dated 7-12-2023 did not identify money management (as identified on Resident #3?s UAI dated 8-22-2023) or the resident?s several allergies (as identified on the personal/social data sheet), including: Alendronic acid, Bactrim, Codeine, Red Dye, Lisinopril, Meloxicam, Nitrofurantoin, or Tolazamide. D. Resident #4 admitted 12-13-2019. Resident #4?s current ISP dated 7-12-2023 did not identify money management (as identified on Resident #4?s UAI dated 7-12-2023). E. Resident #5 admitted 2-27-2023. Resident #5?s current ISP dated 11-13-2023 did not identify a Quinidine or Sulfate Salt allergy that was identified on the resident?s personal/social data sheet. F. Resident #6 admitted 9-06-2017. Resident #6?s current ISP dated 7-18-2023 did not identify money management (as identified on Resident #6?s UAI dated 7-18-2023); nor bowel and bladder assistance as identified on the UAI. G. Resident #7 admitted 6-02-2021. Resident #7?s ISP dated 7-20-2023 did not identify money management (as identified on Resident #7?s UAI dated 7-20-2023). H. Resident #8 admitted 1-14-2020. Resident #8?s ISP dated 9-26-2023 did not identify money management (as identified on Resident #8?s UAI dated 9-26-2023). I. Resident #9 admitted 9-06-2021. Resident #9?s ISP dated 9-13-2023 did not identify money management or stairclimbing assistance (physical assistance) (as identified on Resident #9?s UAI dated 9-13-2023. J. Resident #10 admitted 9-13-2021. Resident #10?s ISP dated 9-25-2023 did not identify money management, stairclimbing (mechanical and human help, physical assistance), and bowel and bladder assistance as identified on the UAI dated 9-25-2023.
Plan of Correction:	1- Residents' records audited. 2- Community will ensure VA DSS Uniformed Assessment Instruments (UAI) and individualized service plans (ISP) are updated timely and residents' needs will be reflected on care plans. 3- Resident care coordinator and director of wellness will be educated on VA DSS Uniformed Assessment Instruments (UAI) and individualized service plans (ISP). 4- Director of wellness/designee will completed random audits. 5- Findings will be reviewed during the next QA meeting.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview with staff, the facility failed to ensure all employees of assisted living facilities had a criminal history record report obtained from the Department of State Police. Evidence: The following two staff members had national criminal checks and not the Department of State Police criminal history record reports on file: A. Staff #6 ? whose date of hire is 6-06-2023; and B. Staff #7 ? whose date of hire is 10-09-2023. Staff #1 confirmed the reports were not submitted as of the second date of inspection.
Plan of Correction:	1- Background records, sworn disclosure forms, and IDs audited of all current staff. 2- Community will ensure new staff will have the VA State police criminal history record prior to the start date with accurate information. 3- Business office director will be educated on the company and the State expectations. 4- Finding will be reviewed during the next QA meeting.
Standard #:	22VAC40-90-50-B
Description:	Based on record review and interview with staff, the facility failed to ensure each criminal history record report was verified by the operator of the facility by matching the name, social security number and date of birth to establish that all information pertaining to the individual cleared through the Central Criminal Records Exchange is exactly the same as another form of identification such as a driver's license. Evidence: Staff #5?s date of hire was 7-19-2023. Staff #5?s criminal records check on file had incorrect spelling of the staff member?s name on the Central Criminal Records Exchange request. Staff #1 confirmed that the original request sent was incorrect and that as of the date of inspection (10-30-2023) had not been correctly resubmitted.
Plan of Correction:	1- Background records, sworn disclosure forms, and IDs audited of all current staff. 2- Community will ensure new staff will have the VA State police criminal history record prior to the start date with accurate information. 3- Business office director will be educated on the company and the State expectations. 4- Finding will be reviewed during the next QA meeting.