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: April 25, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-25-2023, 1:46 ? 2:30 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 3-13-2023 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 87 Number of resident records reviewed: 2 Number of staff records reviewed: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that prior to a resident?s admission to the safe, secure environment (SSE), the resident was assessed by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. Evidence: 1. Resident #1 admitted 1-30-2023. Resident #1?s ?Assessment of Serious Cognitive Impairment? dated 1-28-2023 answered ?No? under ?Does the individual named above [Resident #1] have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia?? 2. Resident #1 resided in the SSE during the resident?s admission in the facility, as confirmed by Staff #1.
Plan of Correction:	The community will ensure that prior to a resident?s admission to the safe, secure environment (SSE), the resident is assessed by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of Dementia, and that the individual is unable to recognize danger or protect his/her own safety and welfare. The community will ensure physician?s understands the paperwork requirements for admission.
Standard #:	22VAC40-73-310-H
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure they not retain individuals presenting an imminent physical threat or danger to self or others. Evidence: 1. Resident #1 admitted 1-30-2023. Resident #1 had nine documented incidents of aggressive behavior in Nurse?s Notes (listed below): a. 1-30-2023: ?Resident hit care team member? threw chair in dining room?? b. 2-05-2023: ?Resident became very agitated upon being redirected, kicked another residents chair and screaming? c. 2-06-2023: ??Resident redirected and yelling and kicking?? d. 2-06-2023: ?The resident pulled a knife on staff that he took from the kitchen?? ? ??It was a butter knife?" e. 2-07-2023: ?Resident very aggressive towards staff?? f. 2-11-2023: ?Resident very agitated and combative. Refused meds and pm care?? g. 2-20-2023: ?Refused afternoon meds? spitting out medication and spitting on other residents and staff?? h. 2-23-2023: ?While eating breakfast, resident started hollering, being bossy? Grabbed residents arm and twisted it. Throwing chairs Hitting residents 911 was called? nothing could be done?.? i. 3-09-2023: ?Hollering, kicking? pushing and hitting employees ?? 2. Additionally, Resident #1?s PCP documented on a visit note dated 2-27-2023, ?Due to [Resident #1?s] high level of anxiety/aggression, I am not certain [Resident #1] is benefiting here, [Resident #1] may benefit from inpatient psychiatric management.? 3. Resident #1 remained at the facility from 1-30-2023 until time of the resident?s passing on 3-12-2023.
Plan of Correction:	Going forward the community will ensure they do not retain individuals presenting an imminent physical threat or danger to themselves or others by reviewing residents on a weekly basis to discuss changes in behaviors and address any concerns immediately.
Standard #:	22VAC40-73-650-C
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure the physician's or other prescriber's oral orders were reviewed and signed by a prescriber within 14 days. Evidence: Resident #1?s record contained a verbal order on 2-09-2023 that documented, ?Start Depakote Sprinkles 125mg po [by mouth] bid [twice daily] dx [diagnosis] mood?; however, the order was not signed by the date of inspection on 4-25-2023 by the prescriber.
Plan of Correction:	Going forward the community will ensure that prescriber?s verbal orders will be signed by a prescriber within 14-days of the order being written by completing a bi-weekly audit of all new orders. New orders will be reviewed by the Director of Health and Wellness, or designee, to ensure compliance.