VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Village at the West End
2422 University Park Boulevard
Richmond, VA 23233
(804) 554-1555

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Nov. 16, 2021 and Dec. 9, 2021

Complaint Related: No

Areas Reviewed:

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

Comments:

A non-mandated self-report inspection was initiated on November 16, 2021 and concluded on December 9, 2021. The current census was 67. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The Senior Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Senior Executive Director a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on December 9, 2021. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on record review and interview with staff, the facility failed to ensure compliance with other relevant regulations and their own policies and procedures. Evidence: 1. A facility internal ?Incident Report? dated 10-01-2021 documented, ?On Friday afternoon @ approximately 5pm, [Staff #2, Title] alerted me to a situation with [Resident #1?s family]. [Staff #2] stated that [Resident #1?s family member] accused [Staff #2] of abusing [Resident #1]. [Staff #2] stated that [Staff #2] was attempting to put the resident?s shoes on to take [Resident #1] to dinner. [Staff #2] said the resident started kicking [Staff #2] so [Staff #2] leaned back and put [Staff #2?s] arm up to protect [Staff #2?s] face?? 2. The facility?s ?Incident Reporting Policy and Process? documented, ?All state reportable incidents will be reported per state regulations?The following items are considered reportable incidents? Violation of Resident Rights, including any form of abuse or allegation of abuse? Any resident and/or staff interactions that could be perceived as abuse, hostile, or unprofessional?? 3. Staff #1 confirmed the 10-01-2021 incident between Resident #1 and Staff #2 was not reported to the central licensing office per incident reporting regulations and the facility?s own policy.
Plan of Correction:	All reportable events, based on the facility?s policies and procedures, as well as relevant state regulations, will be reported to the licensing inspector within 24 hours of the occurrence.
Standard #:	22VAC40-73-325-B
Description:	Based on record review and interview with staff, the facility failed to ensure a fall risk rating was updated after a fall. Evidence: 1. Resident #1?s ?Nurse?s Notes? dated 10-21-2021 (5:00 p.m.) by Staff #1 documented, ?Late report made to DSS regarding Fall on 11-7 shift on 10/17. DSS recommended reporting to APS due to the abrasions of unknown origin on the resident?s face.? 2. Staff #1 confirmed there was no fall risk rating for the fall documented on 10-17-2021.
Plan of Correction:	A Fall Risk Rating will be completed by the Administrator or designee after each fall.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to ensure resident prescription medications were refilled in a timely manner to avoid missed dosages. Evidence: 1. The facility?s Medication Orders policy documented, ?Each prescription medication will be prescribed in writing by an authorized prescriber and kept current?. 2. Resident #1?s October 2021 MAR documented the resident did not receive medications for the following reasons: ?reorder?, ?reordered?, ?not available?, ?on order?, ?Med n/a. Ordered through pharmacy?, ?Medication not available on med cart?.?, ?unavailable?, and ?awaiting pharmacy?. 3. Resident #1 did not receive the following medications on 10-23-2021 ? 10-26-2021 in addition to dates below: a. Mirtazapine 30 mg: 10-02-2021, 10-05-2021, 10-08-2021, 10-10-2021, and 10-11-2021; b. One-tab daily tab multivitamin: 10-08-2021; c. Haloperidol: 10-24-2021 ? 10-26-2021; and d. Aspirin EC 325 MG, Dicyclomine 10 mg, Finasteride 5 mg, Magnesium Oxide 250 mg, Potassium CL ER 10 MEQ, and Sertraline HCL 100 mg. 4. Staff #1 confirmed during interview the aforementioned medications were not refilled in a timely manner to avoid missed dosages.
Plan of Correction:	All medication reorder requests will be submitted at least 5 days prior to the run-out date of the medications. The Director of Health and Wellness, or designee, will perform weekly audits to ensure this is being completed.