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: Feb. 25, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-80 COMPLAINT INVESTIGATION

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: 02/25/2025 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 01/30/2025 regarding allegations in the area(s) of: Physical Abuse Number of residents present at the facility at the beginning of the inspection: 112 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Observed the residents eating in the dining hall and walking around fellowshipping. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Roberts, Licensing Inspector at 804-495-5956 or by email at Alexandra.n.roberts@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-340-B
Complaint related:	Yes
Description:	Based on record review and staff interview, facility failed to ensure that the administrator or his designee documents that the individual's psychosocial and behavioral history were reviewed and used to help determine the appropriateness of the admission. Evidence: 1. Resident 1?s (Admitted: 2/13/24) hospital history and physical indicates Resident 1 is diagnosed with paranoia, hallucinations, mood disorder, and a psychological disorder. Resident 1 is prescribed an antipsychotic (Seroquel 25mg), antidepressant (Lexapro) and a hypnotic (Ativan). 2. Staff 1 confirmed that they do not have documentation that Resident 1?s history was reviewed to help determine appropriateness of admission.
Plan of Correction:	Administrator and Wellness Director reviewed the process of obtaining the psychosocial and behavioral history, including medications with support from the Vitality Operations and Clinical team. An audit of current residents with a history of psychosocial or behavioral needs will be completed by 6/30/2025 and referrals will be made to third party providers as appropriate with consent from the resident and/or POA Executive Director or Designee will conduct an audit of three (3) random resident files per month X 3 months to confirm compliance to the regulation is met.