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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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 1:10 p.m.-3:15 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 1-2-24 regarding allegations in the area(s) of: resident care and staffing. Number of residents present at the facility at the beginning of the inspection: 99 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s) area(s) of non-compliance with standard(s) or law were: Staffing on the memory care unit. A violation notice was 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 #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on a review of staff schedules, the facility failed to ensure that during night hours, the following number of direct care staff members shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents: When 22 or fewer residents are present, at least two direct care staff members. Evidence: The staff schedule for 11:00 p.m.- 7:00 a.m. shift for the last week of December 2023 indicated the following: -On 12-31-23 there was only one staff person on the first floor memory care unit with a census of 16 residents and only one staff person on the second floor memory care unit with a census of 20 residents.
Plan of Correction:	1- Nursing assignment sheet and master shift schedule reviewed and updated. 2- Community shift coverages will be noted on assignment sheet daily to meet residents? needs. 3- Resident care coordinator and director of wellness will be educated by ED on accurate shift scheduling and assignments. 4- Findings will be reviewed during the next QA meeting.