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: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

Mental Health Screening completion

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-25-2023, 9:15 a.m. ? 1:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 87 Number of resident records reviewed: 10 Number of staff records reviewed: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1180-B
Description:	When there are indications that ordinary objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. Resident #1 admitted 11-21-2022. Resident #1?s Nurse?s Notes dated 12-22-2022 documented, ?Resident [#1] observed waking his neighbor up telling him to get up and get out. Redirected several times resident continued. Resident refused medication, squeezing the cup from the writers hand saying I?m not taking it I don?t want it. Resident gave the medication back to the writer when asked for it. A large pair of scissors was observed laying beside the residents pillow. Scissors are now in the office. Resident upset that writer has his scissors ?? 2. Staff #1 confirmed during interview that Resident #1 had obtained a pair of scissors without staff authorization.
Plan of Correction:	Weekly room sweeps will be conducted by the Memory Care Director, or designee, and documented to ensure that any ordinary objects that may be harmful to a resident will be inaccessible to the resident except under staff supervision. Additionally, new family members will be counseled on the importance of not bringing in ordinary objects that may be harmful to residents with a cognitive impairment.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #2 admitted 4-25-2022. Resident #2?s ISP dated 4-19-2023 documented the resident?s allergy to pork; however, did not include allergies listed on the personal/social data form including the following: Fish, Iodine, Metformin, Ace inhibitors, Iodinated diagnostic agents, Ginseng, and Siberian.
Plan of Correction:	Going forward, the Executive Director, or designee, will review and update the individualized service plans every 12 months and as-needed for a significant change of a resident?s condition to include an accurate listing of current allergies.