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: Jan. 13, 2023

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: 1-13-2023, 12:21 ? 1:15 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 12/06/2022 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 89 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Admission, Retention and Discharge of Residents; Resident Care and Related Services 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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure the residents? physical examinations contained a description of the person?s reactions to any known allergies. Evidence: Resident #1 admitted 12-27-2022. Resident #1?s Report of Resident Physical Examination dated 11-30-2022 documented the resident has the following allergies: Ciprofloxacin, Codeine, Demerol, Keflex, Latex (Moderate), Losartan, Macrobid, Melatonin, Metformin, Nitrofurantoin, Oxycodone, Oysters (Moderate), Peanut-containing Drug Products, Penicillin, Quetiapine (Moderate), Shellfish-derived Products, Sulfa Antibiotics, Tetatnus Toxoids (Moderate) Resident #2 admitted 5-23-2022 Resident #2?s Report of Resident Physical Examination dated 5-18-2022 documented the resident has an allergy to Ciprofloxacin. No reactions to known allergies were listed for Resident #1 or Resident #2.
Plan of Correction:	Going forward, both the Director of Health and Wellness and the Executive Director, or their designees, will review the Health & Physical before the resident moves in to the community to ensure allergy reactions are listed appropriately. An audit will be conducted on existing Health and Physicals to ensure reactions are listed and will updated as-needed.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there is a significant change in a resident?s condition. Evidence: Per Resident #2?s Home Health notes, the resident began using a wheelchair per recommendation as of 11-29-2022 due to falls from low blood pressure. Additionally, Home Health notes document the resident was in wheelchair on 12-01-2022 and 12-07-2022 during visit. The primary providers? care notes documented the resident was in his wheelchair on 12-19-2022, 12-21-2022, and 1-06-2023; however, Resident #2?s UAI stated wheelchair use is not performed. Email exchange with Staff #1 documented, [Resident #2] was admitted with a wheelchair for use as-needed since May 2022 but primarily used his walker, eventually he did start using his wheelchair regularly.
Plan of Correction:	Going forward the Director of Health and Wellness and Executive Director, or their designee, will discuss any significant changes in resident conditions on a daily basis and ensure the UAI/ISP are updated accordingly. An audit will be conducted on existing resident UAIs to ensure they are updated with all significant changes.