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: Feb. 23, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced complaint investigation was conducted on February 23, 2022 from 12:19 p.m. to 1:09 p.m. in regards to call bells not being operational. The Executive Director was present. A tour of the facility to include testing of call bells was performed. Resident interviews were conducted. Staff communication with the Executive Director regarding Building and Grounds were continued via email through March 18, 2022. Violation(s) were found in the area of Resident Care and Related Services and Buildings and Grounds. Thank you for your cooperation with this inspection. I can be reached at alex.poulter@dss.virginia.gov or 804-662-9771 with any questions.

Violations:

Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on observation and interview with staff, the facility failed to ensure all equipment was kept in good repair. Evidence: 1. During a tour on 2-23-2022, two pull cords in resident rooms did not activate to the ?Rcare? system. 2. On 3-01-2022, Staff #1 stated, ?Our Maintenance team has been testing pull cords and they are not consistently communicating with the Rcare system, we are not sure of the reason yet. We have reached out to the manufacturer to try and do some troubleshooting. All pendants seem to be working normally.? 3. Staff #1 stated on 3-15-2022 in email, ?We have found that the pendants are working consistently but not the pull cords, and if the pull cords aren?t working they may not be showing up on our diagnostic report.? 4. Based on the aforementioned information, the pull cord equipment is not in good repair.
Plan of Correction:	Once the system has been upgraded, random weekly tests will be conducted to ensure the system is operating correctly. The tests will be documented and maintained by the Executive Director, Maintenance Director, or designee.
Standard #:	22VAC40-73-930-A
Complaint related:	Yes
Description:	Based on observation and interview with staff, the facility failed to ensure a signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom alerted the direct care staff that the resident needs assistance. Evidence: 1. On a tour of the facility with Staff #1 on 2-23-2022, Staff #1 tested an unoccupied room?s signaling device (room A-208) in the connecting bathroom using the pull cord. Staff #1 checked the ?Rcare? system on the medication cart and showed that the pull cord for room A-208 did not activate on the system. 2. Additionally on 2-23-2022, Staff #1 tested an occupied room?s signaling device (room A-203) in the bedroom using the pull cord. Staff #1 checked the ?Rcare? system on the medication cart and showed that the pull cord for room A-203 did not activate on the system. 3. An email dated 2-25-2022 at 5:14 p.m. from Staff #1 documented, ??[Staff #1] had maintenance do some tests yesterday and today and it looks like if a pull cord has a ?low battery? it doesn?t always ring to the Rcare system, which [Staff #1] was not aware of. Other tests we did with other units seemed to be working fine, but [Staff #1] want to continue to test them periodically to make sure it?s consistent?? 4. Staff #1 provided the ?System Diagnostic Report? for 2-23-2022 that addresses the pull cords, and there were 17 ?Low Battery? problems listed for either resident bathroom, bedroom, or pendants. 5. Based on above information, the facility failed to ensure the signaling devices easily accessible to the residents did not alert direct care staff that resident needs assistance.
Plan of Correction:	The community has contacted Rcare to upgrade the call-bell system to ensure all pull cords will be fully operational and accessible to residents in both their bedrooms or connecting bathrooms. Rcare and the community maintenance team will also conduct a full audit during the upgrade to ensure all equipment is in good working order. Additionally, after the upgrade, the Executive Director, Maintenance Director, or designee, will review the System Diagnostic Report on a daily basis to confirm that all batteries are changed and any diagnostic concerns are addressed immediately.