VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vitality Living Arlington
3821 Wilson Boulevard
Arlington, VA 22203
(703) 294-6875

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: Oct. 17, 2024 and Oct. 18, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

The facility should ensure that Durable Do Not Resuscitate (DNR) orders are readily available to authorized persons when necessary. The code status should be accurate on all resident documents.

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: 10/17/2024 Time In: 1:30 PM Time Out: 3:44 PM 10/18/2024 Time In: 8:38 AM Time Out: 4:27 PM 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: 119 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI observed a medication pass. LI observed residents eating lunch and dinner, entering and exiting the facility for community outings, residents engaging with visitors, residents interacting with staff, residents watching television in the main lobby, and residents participating in physical therapy. Additional Comments/Discussion: 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on resident record review and staff interview, the facility failed to ensure to obtain written approval prior to placing a resident with a serious cognitive impairment, in a safe, secure environment. Evidence: 1. Resident 3 (admit date, 07/09/2024) approval for placement in special care unit was completed on 07/25/2024. 2. On 10/18/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that Resident 3?s approval for placement in special care unit was completed after admission.
Plan of Correction:	? Memory care admission will have to have approval of placement form responsible party prior to admission. ? DOW and MCD will audit all admission before completion of admission to ensure proper authorization is in place for admission to MC ? ED educated DOW and MC Director that all forms need to be fully completed ? ED to be final approval and verify at contract signing with POA to ensure is in place at contract signing.
Standard #:	22VAC40-73-70-A
Description:	Based on facility record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. Evidence: 1. On 08/09/2024 four residents and one staff tested positive for COVID. On 08/10/2024 two residents and one staff tested positive for COVID. On 08/11/2024 two residents tested positive for COVID. On 08/12/2024 three residents and one staff tested positive for COVID. On 08/13/2024 one resident tested positive for COVID. 2. Fifteen residents tested positive for COVID, and it was not reported to the licensing office. 3. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who stated Arlington County Public Health Division was contacted on 08/13/2024. Staff 6 stated the reporting policy for COVID was lifted and was unaware that this was something that should still be reported to licensing. 4. On 10/17/2024, LI received an email from Staff 7 sharing the Vitality Living Respiratory Line List. The Respiratory Line List showed the names of residents and staff that tested positive for COVID, the onset dates, and dates of COVID testing. 5. On 08/08/2024 Resident 3 was found on the floor, lying on the right side, next to the nightstand. Resident 3 was transported to Virginia Hospital Center diagnosed with a head injury. This incident was not reported to licensing. 6. On 10/17/2024, LI requested a list of falls since July 2024. Staff 7 provided the name and incident report of Resident 3.
Plan of Correction:	? Notify all covid cases within 24 hours to the state effective immediately ? There have been no cases since date of inspection ? ? Educated all leadership on 11/25/24 that moving forward that ALL COVID cases need to be reported to VDSS as well. ? Results /Findings reviewed at next QA meeting ? Notify State of any injury related to fall effective immediately ? ED and DOW responsible for this action ? will review at every QA meeting. ? ED and or DOW to notify VDSS on all falls with injury. ? Inservice in place to educate staff when fall occurs ? and reporting related to fall. ? Dow or designee will review any falls at daily alignment from day before. ? Results and Findings reviewed at all QA Meetings with Leadership
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure that each direct staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff 4?s (hire date, 05/13/2022) first aid certification was not provided upon request. 2. On 10/18/2024, licensing inspector (LI) interviewed Staff 6 who confirmed that Staff 4?s first aid certification was not present in the record. 3. Staff 5?s (hire date, 07/16/2024) first aid certification expired on 09/11/2024. 4. On 10/18/2024, LI interviewed Staff 6 who stated that Staff 5 was a first aid instructor and was positive that Staff 5 had an updated certification. Staff 6 stated an intention to contact Staff 5 for an updated certification. LI was not provided an updated first aid certification for Staff 5.
Plan of Correction:	? Staff members 4,5,6 will have completed CPR training 1/30/25 ? Continuation of staff records and licensure will be audited by BOD and reviewed at QA meeting with leadership ? Ed or Designee will conduct random audit for new or current employee that we are compliant with certification. Education provided to leadership to ensure compliance. ? ED to verify and bring to QA
Standard #:	22VAC40-73-320-A
Description:	Based on resident record and staff interview, the facility failed to ensure that a residents? physical examination contained the following: the person?s address, blood pressure, and general physical condition, including a systems review as is medically indicated. Evidence: 1. Resident 8?s (admit date, 09/04/2024) physical examination was missing Resident 8?s address, blood pressure, and general physical condition, including a systems review. 2. On 10/18/2024, licensing inspector (LI) interviewed Staff 8 who confirmed that the address, blood pressure, and general physical condition sections were left blank on the physical examination form.
Plan of Correction:	? Ensure physical examinations are completed and every section is filled out prior to admission moving forward. ? Audit files to ensure that they are filled out the person?s address, blood pressure, and general physical condition, including a systems review as is medically indicated. ? Finding will be reviewed by the team at the next quality assurance meeting
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. Evidence: 1. Resident 2 (ISP date, 08/15/2024), Resident 3 (ISP date, 08/13/2024), Resident 5 (ISP date, 10/10/2024), Resident 6 (ISP date, 08/06/2024), Resident 7 (ISP date, 05/23/2024), and Resident 8?s (ISP date, 10/10/2024) individualized service plans were not signed and dated by the residents or their legal representatives. 2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who confirmed that the individualized service plans were not signed or dated. Staff 6 stated they would work on getting signatures on all plans.
Plan of Correction:	? ISP on resident 2,3,5,6,7,8 has been completed and signed ? Ensure responsible parties are signing off on the ISP. ? ISP will be signed in person or via docu sign going forward. ? If unable to obtain signature state in the ISP. ? DOW and Wellness coordinator to audit monthly for signatures. ? Results and Findings reviewed at all QA Meetings with Leadership
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that the individualized service plans were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident 9?s (admit date, 06/28/2024) special diet was not included in the individualized service plan (08/04/2024).
Plan of Correction:	? Review ISP for diet orders to ensure diet orders are mentioned in the ISP complete by 1/30/25
Standard #:	22VAC40-73-610-B
Description:	Based on LI observation and staff interview, the facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents. Evidence: 1. A daily menu was displayed on a television in the lobby. 2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who stated that the daily menu was posted as a PowerPoint slide on the television screen in the lobby. Staff 6 confirmed that it was a daily menu posted that the residents are able to swipe through to the next day. 3. On 10/17/2024, LI observed the daily menu posted on the television screen. LI observed Staff 6 attempt to swipe to the next day. The presentation would not slide. Staff 6 stated, ?the screen must be locked.? Staff 6 requested assistance from the dining department. LI observed that the USB was not in the television which was required for residents to view the rest of the menu. Staff 6 placed the USB in the television and was able to show LI how residents are able to move through the presentation. 4. Photo evidence taken.
Plan of Correction:	? Menus posted by Dining Room ? Menus are displayed on Electronic Board ? the weekly and monthly plus everyday options and snacks on Menu available. ? Dining leadership will verify posted menus are up to date ? Menu Chats conducted with residents to educate and inform of options. ? Paper menus also posted for resident review ? Results and Findings reviewed at all QA Meetings with Leadership
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that each resident?s prescription medications and any over-the-counter (OTC) drugs and supplement ordered for the resident were filled and refilled in a timely manner to avoid missed dosages. The facility failed to prevent the use of outdated, damaged, or contaminated medications. Evidence: 1. Resident 2 (admit date, 01/01/2020) had an order for Lidocaine Pain Relief 4% Cream, order date, 05/17/2023 (apply topically to affected area of neck/low back three times daily as needed for pain). Lidocaine Pain Relief 4% Cream was not on-site for self-administration. 2. On 10/18/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that the Lidocaine Pain Relief 4% Cream was not found in the medication cart. Staff 7 stated, ?I will check downstairs overflow.? LI completed the medication review and returned to the main level and executive office suites. Staff 7 did not provide the medication from the ?downstairs overflow.? 3. Resident 5 (admit date, 12/31/2015), who self-administers medication, had an order for Acetaminophen 325 MG, order date, 08/02/2022 (take 2 tablets (650 mg) by mouth every 6 hours as needed for moderate pain). Acetaminophen 325 MG was not on-site for self-administration. 4. On 10/18/2024, LI interviewed Resident 5 who stated, ?I don?t have Tylenol. That?s what I use Naproxen for, works better than most anything.? 5. Resident 5 had an order for Aveeno Daily Moisturizing 1.2% Lotion, order date, 08/02/2022 (assist patient with apply lotion topically to both arms every day as needed for skin deficiency). Aveeno Daily Moisturizing 1.2% was not on site for self-administration. 6. On 10/18/2024, LI interviewed Resident 5 who stated, ?I don?t use that that anymore. I use Excedrin. There?s no doctor?s order. I have very dry skin. 7. Resident 5 had an order for Combivent Respimat 20-100 MCG, order date, 01/12/2024 (inhale 1 puff twice daily). Combivent Respimat 20-100 MCG was not on site for self-administration. 8. On 10/18/2024, LI interviewed Resident 5 who stated, ?when I was in the hospital they gave it to me. I had the flu and was told to take it for a week. It?s gone now? been gone for a while.? 9. Resident 5 had an order for Culturelle Digestive Health, order date, 08/02/2022 (take 1 capsule by mouth every day * do not crush). Culturelle Digestive Health was not on site for self-administration. 10. On 10/18/2024, LI interviewed Resident 5 who stated, ?I don?t take it anymore.? 11. On 10/18/2024, LI interviewed Staff 7 who stated, ?that?s what you take with antibiotic. That should have been discontinued. Why it?s there, I don?t know.? 12. Resident 5 had an order for Sea-Clens Wound Cleanser, order date, 01/30/2023 (cleanse open area on R ishium and R buttock, pat dry, apply calcium alginate, cover with border foam dressing twice weekly). Sea-Clens Wound Cleanser was not on site for self-administration. 13. On 10/18/2024, LI interviewed Resident 5 who stated ?that was for the wound on my leg. It?s all fixed now. I don?t take it anymore.? 14. Resident 5 had an order for Baclofen 20 MG, order date, 08/02/2022 (take one tablet by mouth three times daily). There were three expired bottles of Baclofen 20 MG on site, expiring 02/08/2023, 04/23/2023, and 07/04/2023. 15. On 10/18/2024, LI interviewed Resident 5 who stated, ?sometimes I combine new drugs into the old bottle.? 16. Resident 5 was self-administering Naproxen Sodium 220 MG without a physician?s order. 17. On 10/18/2024, LI interviewed Resident 5 who stated, ?I got it from my online pharmacy. I only take it when I have a headache.? 18. Resident 5 was self-administering Methenamine HIPP 1 GM without a physician?s order. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of Correction:	? #1-26 have all been corrected . ? Inspect med carts and orders to ensure that each resident?s prescription medications and any OTC drugs and supplement ordered for the resident were filled and refilled in a timely manner. Complete by 1/30/25 ? Asses self-med residents every 6 months. ? Ensure medications have active orders and matches with what is being self-administered. Complete by 1/30/25 ? Encourage residents to notify nurses with any changes. ? Ongoing encouragement and education with Independent resident on the importance of audits and self medication management. ? DOW or designee to perform random audit of one resident each month for 7 months.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that no medication or dietary supplement was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter (OTC), and sample medications. Evidence: 1. Resident 2 (admit date, 01/01/2020) had Acetaminophen 325 MG (take 2 tablets (650 MG) by mouth every 6 hours as needed for mild pain, headaches, or fever for up to 30 doses) stored in the medication cart. Resident 2?s Physician Order Review (10/18/2024), September 2024 medication administration record (MAR), and October 2024 MAR did not include an order for Acetaminophen 325 MG. 2. On 10/18/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that Resident 2 did not have an order for Acetaminophen 325 MG.
Plan of Correction:	? Review every chart for diet and medication order changes to ensure that no medication or dietary supplement was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Complete by 1/30/25 ? Finding will be reviewed by the team at the next quality assurance meeting
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review and staff interview, the facility failed to ensure the resident record contained the physician?s or other prescriber?s signed written order. Evidence: 1. Resident 9?s (admit date, 06/28/2024) record contained a Physician?s Diet Order document with the box marked with an X for a Carbohydrate Controlled Diet that did not contain a signature for the physician or other prescriber. 2. On 10/17/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that the physician?s diet order form was completed on the day of admission on 6/28/2024 and was not signed.
Plan of Correction:	? Review charts for diet orders ensuring all current orders are signed by MD or NP and matches with Yardi complete by 1/30/25
Standard #:	22VAC40-73-720-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that Do Not Resuscitate (DNR) Orders were only carried out in a licensed assisted living facility when the written order was included in the individualized service plan. Evidence: 1. Resident 6?s (admit date, 04/27/2023) record contains a Durable Do Not Resuscitate (DNR) order dated 02/07/2024. 2. Resident 6?s individualized service plan dated 08/06/2024 has ?FULL CODE? stamped in red at the top of the first page and is not written as an identified need within the document. 3. On 10/18/2024, LI interviewed Staff 5 who confirmed that the plan stated, ?full code.?
Plan of Correction:	? Resident #6 ISP updated at time of inspection and DNR was updated as well at time of inspection ? DOW or designee to Review charts for DNR documents, update EHR and ISP?s with proper code status complete by 1/30/25 ? Inservice with ? DOW and ED to coordinate verify charts quarterly moving forward and will be reviewed at QA meeting with Leadership.
Standard #:	22VAC40-73-830-E
Description:	Based on facility record review and staff interview, the facility failed to ensure to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns. Evidence: 1. June, July, and September 2024 (06/26/2024, 07/24/2024, 09/25/2024) resident councils did not include a written response to the residents. 2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who confirmed that there were not any written responses to the resident councils. Staff 6 stated that the ?concern/suggestion/feedback? section was not used by staff to respond to the resident concerns.
Plan of Correction:	? Correction has been Implemented and responses added to the issues brought up by Residents at the monthly meetings on 11/15/2024 ? Responses are in the notebook where minutes are kept from the meetings when applicable. ? 12/6/2024 Resident council meetings for 2024 were reviewed by Engagement Director and unresolved items were addressed where needed. ? 11/18/2024 Management team in-service by ED on the procedure for addressing issues from resident specific meetings when applicable ? ED or designee will monitor resident meeting minutes for issues/concerns that need to be addressed and will verify that such items are being resolved moving forward ? Finding will be reviewed by the team at the next quality assurance meeting
Standard #:	22VAC40-73-970-E
Description:	Based on facility record review and staff interview, the facility failed to ensure that the record included the number of residents participating, any special conditions, the time it took to complete the drills, and problems encountered, if any. Evidence: 1. June ? September 2024 (06/28/2024, 07/31/2024, 08/24/2024, 09/23/2024) fire drills were missing the number of residents participating, any special conditions simulated, the time it took to complete the drill and problems encountered. 2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who stated being unaware that the form did not have the necessary information. Staff 6 stated that the form will be updated to include all necessary information.
Plan of Correction:	? Drills conducted in October and November were completed and signature were obtained , ? We have ensured that signature proof of resident participation is documented and part of the Emergency Log ? Executive Director or designee will conduct an audit of the fire drill documentation monthly x six months to verify adherence to the regulation ? 11/1/2024--Environmental Services Director and team were Inservice by ED on the acceptable documentation as it relates to fire drills conducted at the community ? Finding will be reviewed by the team at the next quality assurance meeting.