VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Riverside Assisted Living at Sanders
7407 Walker Avenue
Gloucester, VA 23061
(757) 693-2000

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: Jan. 27, 2020

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted on 12-17-19 (ar 08:05 am/dep 18:15 pm) and 12-18-19 (ar (09:20 am/dep 16:30 pm). The facility census on day 1 was 27. A tour of the facility was conducted, call bells were tested, hot water temperature checked, breakfast meal observed, emergency preparedness documents reviewed; staff and resident interviews conducted and staff and resident records were reviewed. Violations and concerns were discussed with facility staff throughout the course of the two day inspection. The violations were reviewed at the end of both days with facility staff. The acknowledgement was signed by the administrator at the end of the exit review on day one and by the executive director on day two following the exit interview. Comment: The LI suggested the facility representative who complete the UAI review the UAI manual for clarity regarding assessments. The LI also informed staff information regarding medication management plan and psychotropic medication would be reviewed with administrator/consultants. Staff was reminded to refer to the glucose protocol listed on the public website for labeling of instruments. LI suggested the facility have a clearer system in place to identify the regulatory requirements for staff orientation. The LI reminded the facility of the requirement for annual review of registry access requirement. Administrator reminded of the incomplete renewal application and the facility's license expiration. Administrator also reminded of the upcoming provider training and the changes/updated information to be included on the disclosure and provide residents/legal representative with updated information to all. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. The plan of correction is due within 10 days. (POC due 1-17-120. Should you have any questions contact your inspector at 757-439-6815.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review and staff interview, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or his legal representative was retained in the resident's record. Evidence: 1. On 12-18-19 during a review of resident #1's and #7's record with staff #1 and staff #2, the residents' records did not have documentation of acknowledging receipt of the facility's disclosure information. The record noted resident #1's date of admission was documented as 11-4-19 and resident #7's date of admission was documented as 3-22-19. 2. On 12-18-19 during a review of resident #1's administrative record with staff #11, the disclosure was not in the resident's record kept in the business office. 3. Staff #1 and #2 acknowledged resident #1 and #7's records did not include documentation of acknowledgement of the facility's disclosure statement.
Plan of Correction:	1. Acknowledgement of receipt of the disclosure statement for resident #1 and resident #7 was signed January 10, 2020. Copies of the acknowledgement were placed in the residents? record. 2. An audit of all residents will be completed by the campus administrator/designee to ensure all residents have an acknowledgement of receipt of the disclosure statement in their record. Employees involved in the admission process will be reeducated by the educator/designee to provide the disclosure statement and to get the acknowledgement of receipt of the disclosure statement signed prior to admission and kept in the resident?s record. 4. Campus administrator/designee will conduct an audit of 2 admissions per month for 3 months to ensure the acknowledgement for the disclosure statement is present in the record. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-310-B
Description:	310-B.3 Based on record review and staff interview, the facility failed to ensure before it made a determination to admit a resident it obtained a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative. Evidence: 1. On 12-17-19 and 12-18-19 during a review of resident #1's record with staff #1 and staff #2, a documented interview between the administrator or a designee responsible for admission and retention decisions on or prior to admission.was not in the record. 2. Staff # 2 and #3 acknowledged residents #1 and #7's record did not contain documentation of an interview between the administrator or designee.
Plan of Correction:	1. Residents #1 and #7 had admissions interviews completed on 1/17/2020. 2. An audit of current resident records will be completed by the assisted living director/designee to ensure admission interviews have been completed and are on filed in the record. 3. Employees involved in the admission process will be reeducated by the educator/designee to how to complete the preadmissions interview prior to or at admission. 4. An audit of all new residents will be completed by the campus administrator/designee for three months to ensure all residents received the preadmissions interviews prior to or on admission. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-310-D
Description:	Based on record review and staff interview, the facility failed to ensure prior to admission, the administrator provided a copy of the written assurance and a signed copy by the resident or legal representative was kept in the resident's record. Evidence: 1. On 12-17-19 and 12-18-19 during a review of resident #1's record with staff #1 and staff #2, there was no documentation of the resident and/or legal representative's acknowledgement of being provided written assurance that the facility had the appropriate license to meet the resident's care needs prior to admission. 2. On 12-18-19 during a review of resident #7's record with staff #2 and #3, the record contained a copy of the written assurance document, however, the date was incomplete (3/ /19). 3. Staff #1, #2 and #3 acknowledged documentation of resident #1's written assurance was not in the record and staff #2 acknowledged resident #7's written assurance date was incomplete.
Plan of Correction:	1. Resident #1 was given a copy of the facility written assurance and a signed copy was placed in their record on /13/2020. Resident #7 was given a copy of the facility written assurance and a signed copy was placed in their record on 3/22/2019. Date was corrected 1/13/2020. 2. An audit of current resident records will be completed by the assisted living director/designee to ensure written assurance has been completed and are filed in the record. 3. Employees involved in the admissions process will be reeducated by the educator/designee as to how to complete the written assurance prior to or at admission. 4. An audit of all new residents will be completed by campus administrator/designee for three months to ensure all residents have signed copies of written assurance in their records. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with prohibitive conditions such as psychotropic medication without a treatment plan. Evidence: 1. On 12-18-19 during a review of resident #5's record, it was revealed that the facility did not have a treatment plan from the prescriber for psychotropic medication being administered by facility staff. The December 2019 medication administration record (mar) noted resident was prescribed Lexapro (depression) and Ativan (anxiety). 2. LI requested a treatment plan for the prescribed psychotropic medication. Staff #2 and #4 provided a copy of resident #5's medication administration record (mar), target behavioral symptoms document. The document is completed by facility staff to document activity (the # of episodes, intervention, outcomes and staff initials) when the medication is administered. According to staff #2, the target behavioral symptoms document and the progress notes from the resident's visit to the doctor is the facility's treatment plan. A review of the progress notes dated 8-8-19 did not include any medications no psychotropic medications. A review of systems referenced psychiatric behavioral: "negative for agitation...." However, there was no documentation of psychotropic medications. The progress report also not "assessment/plan", however, this section did not document psychotropic medications or reason for use of Ativan and Lexapro. A review of the section of the progress report noted "Visit diagnoses" noted multiple diagnoses, however, no diagnosis was documented for the prescribed medications Lexapro and Ativan.
Plan of Correction:	1. Prescribing physician for resident #5 was contacted 1/7/2020 by assisted living director to clarify the medication list and treatment plan for the psychotropic medications being administered. 2. An audit of all resident medication lists will be completed by the assisted living director/designee for psychotropic medications and treatment plans Medication lists for all prospective admissions will be reviewed prior to admission to ensure plan of care and diagnosis are accurate and in place. 3. Staff will be educated by the educator/designee on the type of medications requiring specific treatment plans and how to obtain plans prior to starting new psychotropic medications. 4. Three medication records will be audited weekly for 8 weeks by assisted living director or designee to ensure treatment plans are in place as needed. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure within 30 days preceding admission, a resident had a physical examination and risk assessment documenting the absence of tuberculosis in a communicable form. Evidence: 1. On 12-18-19 during a review of resident #7's record with staff # 5 and #7, the physical examination and tuberculosis (tb) information was dated 4-4-19. Resident #7's personal social data in the record noted a date of admission of 3-22-19. 2. Staff #5 and #7 acknowledged the physical examination and tb results for resident #7 was completed after the date of admission.
Plan of Correction:	1. Resident #7 received her tuberculosis screening 4/4/2019, 13 days after her admission to Assisted Living. Resident?s physical exam was completed 4/4/2019. Resident had screens done prior to their admission to campus in 2017. 2. An audit of all residents will be complete by the campus administrator/designee to ensure all residents received physical examinations and tuberculosis screening prior to admission. 3. Employees involved in the admission process will be reeducated by the campus administrator/designee to the necessary health screening prior to admission. 4. An audit of 2 admissions a month for 3 months will be completed by campus administrator/designee to ensure the physical exam and tuberculosis screening is completed. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-350-B
Description:	Based on record review and staff interview, the facility failed to ensure it ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days and document in the resident's record the date the information was obtained. Evidence: 1. On 12-18-19 during a review of resident #7's record with staff #3 and #4, the record did not contain documentation of the facility's documentation of a sex offender check. Resident #7's date of admission was documented as 3-22-19. 2. Staff #4 acknowledged resident #7's record did not have documentation of a sex offender report.
Plan of Correction:	1. Resident #7 had a sex offender registry check run within 30 days of being admitted to the campus but not within 30 days of being admitted to Assisted Living. A se offender registry check was run on 1/9/2020. 2. An audit of all residents will be completed by the campus administrator/designee to ensure all residents have a sex offender registry check. 3. Employees involved in the admission process will be reeducated by the educator/designee to complete sex offender registry checks prior to transitions between levels of care on the campus prior to the transition. 4. An audit of 2 admissions per month for three months will be completed by the campus administrator/designee to ensure the sex offender registry check is completed ad filed in the resident?s record. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-410-A
Description:	Based on record review and staff orientation, the facility failed to ensure a resident's record contained documentation acknowledging having received orientation. Evidence: 1. On 12-17-19 and 12-18-19 during a review of resident #1's record with staff #1 and staff #2, resident #1's record did not contain signed and dated documentation by the resident and/or legal representative of having received orientation to the facility. 2. On 12-18-19 during a review of resident #7's record with staff #2, #3 and #4, the record did not contain documentation of orientation to the facility. 3. Staff acknowledged resident #1 and #7's record did not contain documentation of orientation.
Plan of Correction:	1. Residents #1 and #7 were provided facility orientation on 1/17/2020. Documentation of the orientation was placed in the record. 2. An audit of all residents will be completed by the campus administrator/designee to ensure al residents have a signed and dated confirmation of orientation to the facility. 3. Employees involved in the admission process will be reeducated by educator/designee to complete and have resident and/or legal representative sign new resident facility orientation. 4. An audit of all new residents will be completed by the campus administrator/designee for three months to ensure all residents have a signed and dates confirmation o orientation to the facility. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-440-H
Description:	Based on record review and staff interview, the facility failed to ensure an annual reassessment using the uniformed assessment instrument (UAI) was utilized to determine whether a resident's need can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 12-17-19 and 12-18-19 during a review of the resident #3's record with staff #1 and #2, the uniformed assessment instrument (UAI) was last dated 12-3-18. Resident's date of admission noted as 8-18-17. The record noted UAI dates: 8-7-17; 9-7-17; and 12-3-18. 2. Staff #1 and #2 acknowledged resident #1's record did not include an annual UAI since 12-3-18.
Plan of Correction:	1. Resident #3 had an annual UAI completed 1/8/2020 by the assisted living director. 2. An audit of all residents will be completed by the assisted living director to ensure all residents have an annual UAI completed. 3. Employees will be re0educated to the annual UAI process by the educator/designee. A new process will be put in place by the assisted living director/designee to track UAI annual dates to ensure timely completion. 4. An audit of 2 residents per week for 8 weeks will be completed by the campus administrator/designee to ensure UAIs are completed timely. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) shall include all assessed needs for residents. Evidence: 1. On 12-17-19 and 12-18-19 during a review of the sampled residents' record with staff, the following residents' individualized service plan did not include the assessed need: Resident #1's uniformed assessment instrument (uai) dated 11-4-9 indicated wheeling not performed, however, the ISP did not indicate assessed need. 2. Resident #2's uai dated 7-25-19 noted bathing (mechanical help/human help/physical assistance-mh/hh/pa); however, the ISP dated 12-8-18 did not include mechanical help(mh). Stairclimbing noted performed, however, the ISP noted guarding...guiding.. physical assistance up/down stairs. 3. Resident #3's uai dated 12-3-18 noted wheeling not performed; however, the ISP dated 12-10-18 noted not performed, but not what services staff will provide to address the need. Stairclimbing noted mechanical help (1022-19) not performed; however, the ISP noted walker (no longer uses stairs 11-27-19). 4. Resident #4's uai dated 12-2-19 noted wheeling (not performed) and the ISP 12-3-19 noted not performed and no description of services staff should performed to address need. Stairclimbing noted human help/supervision; however, the ISP noted human help/ supervision with guarding..guiding. 5. Resident #5's uai dated 12-2-19 noted wheeling not performed, however, the ISP dated 12-15-18 did not provide description of services to be provided to address assessed need. 6. Resident #6's uai dated 10-28-19 noted toileting mechanical help (mh); however, the ISP dated 12-4-18 indicated does not need help. Wheeling indicated not performed, however, the ISP noted note performed not the description of services needed to address the assessed need. 7. Resident #7's uai dated 3-22-19 noted walking (mechanical help), cane; however, the ISP noted resident is independent- does not need help. 8. Staff #1 and #2 acknowledged the ISP was not consistent with the assessed documentation for the aforementioned residents.
Plan of Correction:	1. Individualized Service Plan (ISP) for resident #1 will be updated to match most recent assessment 1/21/2020. Resident #2?s ISP will be updated to match the most recent assessment 1/21/2020. Resident #3?s Assessment and ISP will be updated to be accurate for resident and match each other. Resident # 4?s Assessment and ISP will be updated to match each other 1/21/2020. Resident #5?s ISP will be updated to match most recent assessment 1/21/2020.Resident #6?s ISP will be updated to match most recent assessment 1/21/2020. Resident #7?s ISP will be updated to match most recent assessment 1/21/2020. 2. An audit of all residents Assessments ad ISPs will be conducted by the assisted living director/designee to ensure al Assessments and ISPs match and are appropriate to the resident. 3. Employees completing Assessments ad ISPs will be re-educated by educator/designee in the correct process for completing both tools. 4. An audit of 2 residents per week for 8 weeks will be completed by the campus administrator/designee to ensure ISPs are accurate and address the resident?s needs. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-450-D
Description:	Based on record review and staff interview, the facility failed to ensure when hospice care is provided to a resident, each service provided shall be included on the individualized service plan (ISP). Evidence: 1. On 12-17-18 during a review of resident #2's record with staff #1 and staff #2, the individualized service plan (ISP) did not clearly care plan each care need/service, when and what services to be provided by the hospice agency staff/facility staff. A review of the resident's contract revealed resident receiving social worker and chaplain services in addition to nursing services. 2. Staff acknowledged all hospice services were not clearly care-planned on the resident #2's ISP.
Plan of Correction:	1. Resident #2?s ISP was updated to include all Hospice services the resident receives 1/17/2020. 2. All hospice residents ISPs will be audited by the assisted living director/designee for accuracy of hospice services received. 3. Employees completing Assessments and ISPs will be re-educated by the educator/designee in the correct process for completing both tools. 4. Assisted Living Director or Designee will complete an audit of 2 hospice resident per week for 8 weeks to ensure ISP addresses hospice services. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-450-E
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee (the person who had developed the plan), and by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. On 12-17-19 during a review of resident #1's record with staff #1, the individualized service plan (ISP) was not signed and dated by the developer. The resident's date of admission was documented 11-4-19 and the uniformed assessment instrument (UAI) was dated 11-4-19. 2. Resident #2's ISP dated 7-28-19 was not signed by the resident and/or legal representative; resident had a change in condition (hospice). 3. On 12-18-19, a review of resident #4's ISP with staff #2, the ISP dated 12-3-19 was not signed by the resident and/or legal representative (annual update). 4. Resident #6's annual ISP dated 10-28-19,was not signed by resident and/or legal representative, UAI dated 10-28-19. 5. Staff #1 and #2 acknowledged residents' #1, #2, #4 and #6's ISP were not signed and dated as required.
Plan of Correction:	1. Resident #1?s ISP will be signed and dated by the developer by 1/21/2020. Resident #2?s ISP will be signed by the resident or legal representative due to change in condition by 1/21/2020. Resident #4?s ISP will be signed by the resident or legal representative by 1/21/2020. Resident #6?s annual ISP will be signed by resident or legal representative by 1/21/2020. 2. All ISPs will be audited by the assisted living director/designee for appropriate dates and signatures. 3. Employees completing ISPs will be re-educated by the educator/designee in the correct process for signing and dating. 4. Assisted Living Director or Designee will complete an audit of 2 residents per week for 8 weeks to ensure all required signatures are present on the ISP. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-640-A
Description:	Based on document review and staff interview, the facility's medication management plan addressing the facility's standard dosage schedule was not able to be determined for compliance. Evidence: 1. On 12-17-19 during the medication observation, the resident's medication administration record did not contain specific times, however, it did include various numbers under the heading "freq". These numbers indicated specific times of the day, but no specific hour/time of the day. For example, all medications with the #1 indicated, before breakfast, but there was no hour of the day. According to staff #7, the time is written on the medication administration record (mar) by staff after administration. 2. Further review of the facility's mar for a resident included a sheet that requested the actual time of the medication administration for each number assigned to a medication. All #1 or #2 or #7 medications time were noted here by the administering staff. This is the only place on the mar where there is a documented time. 3. Further review of the facility's medication management plan indicated " medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule'. The facility medication management provided the LI plan did not include medication administration guidelines for the "Medication administration codes and timeframes" /Household Model Personalized Medication Program" observed.
Plan of Correction:	1. Medication Management plan was provided for surveyor on December 18, 2019, and again on December 30, 2019. Further information was requested by survey agency on January 14, 2020 and was provided January 15, 2020 for survey agencies approval of the plan. 2. Other required policies and plans will be reviewed by the campus administrator/designee to ensure that do not require Survey agency approval. 3. Education was provided by the campus administrator /designee to the Assisted Living Director on the need for DSS approval for any changes to the medication management plan. 4. An audit will be conducted monthly to review changes/updates to DSS Assisted Living policies/regulations for changes and updates. Results will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-830-E
Description:	Based on document reviewed and staff interviewed, the provider failed to ensure it provided 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. On 12-18-19 during a review of the facility's resident council meeting minutes with staff #2 and #3, the reports noted residents' concerns, however, there was no documentation of the the written response to by council regarding resolution of problems or concerns.
Plan of Correction:	1. Assisted Living Director provided follow up from previous resident council concerns to residents prior to the January 14, 2020 resident council. Resident Council concerns will be posted with responses prior to the next meet and be available to residents and reviewed with residents immediately prior to the meeting. 2. A review of the last three months of resident council minutes was completed by the assisted living director and follow up from concerns expressed will be communicated to the residents by January 21, 2020. 3. Employees involved with resident council will be educated by the campus administrator/designee to address and respond to concerns from resident council to the Assisted Living Director within 7 days of the council meeting and reviewed with the resident immediately prior to the next resident council meeting. 4. Campus Administrator/designee will audit resident council minutes for 3 months to ensure all concerns are being responded to and residents are receiving those responses. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interview, the facility failed to ensure the hot water at taps available to residents were maintained within a range of 105 degrees and 120 degrees Farenheit (F). Evidence: 1. On 12-17-19 during a tour of the facility with staff #1, the hot water temperature in room #106 was 123.7 degrees; room #107 was 122.2 degrees; and room #214 was 120.6 degrees. 2. Staff #1 acknowledged the hot water temperatures were greater than 120 degrees Fahrenheit (F).
Plan of Correction:	1. Hot water heaters were adjusted by facilities team on December 17, 2019 to ensure hot water. 2. Routine monthly checks will be audited to campus administrator/designee to ensure desirable rangers are achieved and maintained and that variances are addressed appropriately. 3. Facilities staff was re-educated by the assisted living director/designee on December 17, 20119 desirable water temperature range. 4. A spot check of 3 rooms per week will be completed by the assisted living director/designee for 8 weeks to ensure temperatures are within desirable range. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.
Standard #:	22VAC40-73-940-A
Description:	Based on document review and staff interview, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Report of the inspection shall be retained at the facility for at least two years. Evidence: 1. On 12-17-19 during a request for the facility's fire inspection per the renewal inspection protocol, staff #2 stated the inspection had not been completed. The facility's documentation of the last fire inspection was conducted 5-16-18. 2. Staff #2 acknowledged the facility did not have an annual fire inspection since 5-16-18.
Plan of Correction:	1. State Fire Marshal?s office has been called multiple times to request an annual Fire Inspection. Fire Marshal arrived January 15, 2020 to complete the annual inspection. Final report will be sent to facility by January 21, 2020. 2. An audit of outside required inspections will e completed by the assisted living director/designee to ensure any other required inspections have been completed timely. 3. Safety Meeting dashboard will be used by the facility services director/designee to track all regular inspecting agencies prior to the inspections expiring. 4. A review of the safety meeting dashboard will be completed by the campus administrator/designee monthly for three months to ensure all required inspections have been completed and appropriate documentation is present. Results of the audit will be reported to QAPI for analysis and trending. 5. January 31, 2020.