VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Blue Ridge Senior Living of Richmond
12411 Gayton Road
Richmond, VA 23228
(804) 741-9494

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: May 27, 2022

Complaint Related: No

Comments:

The inspector was onsite at the facility on the following days to conduct an unannounced non-mandated follow up inspection: On 04/19/2022 between the approximate time of 9:52 a.m. until 4:11p.m; 04/28/2022 between the approximate time of 8:00a.m until 12:05p.m 05/03/2022 between the approximate time of 10:00a.m and 11:42a.m The facility offered 95 residents in care. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection supported some but not area(s) of non-compliance with standard(s) or law were. A violations issued that were 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 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observation and interview with staff, the assisted living facility failed to implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) blood borne pathogens regulations. Evidence: The CDC website updated 02-02-2022 refers to use of respirators or well-fitting facemasks or cloth masks to cover a person?s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. During the walk through of the facility on 04/19/2022 the inspector observed that facility staff #4 on three different occasions interacting with other facility staff and residents with her mask pulled down below her mouth and nose. Later while accompanied by the facility Administrator facility staff #4 was again observed with her mask pulled down below her mouth and nose.
Plan of Correction:	FACILITY'S RESPONSE- "Employees will be in serviced on Infection Control to include CDC website on wearing masks. "
Standard #:	22VAC40-73-120-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that orientation and training required occurred within the first seven working days of employment. Evidence: Facility staff #6-Documented date of hire 01/13/2022 Facility staff #s 7 and 8- Documented date of hire unknown Upon request during the review of facility records on 04/19, 28/2022 the facility did not submit for the inspector?s review documented evidence that orientation had been provided to the staff #s 6, 7 and 8 within the first seven working days of employment.
Plan of Correction:	FACILITY RESPONSE- "Business Office Manager to do a complete audit of employee files and any missing documentation will be completed. New Hire Orientation will occur weekly and will count as employee start date."
Standard #:	22VAC40-73-150-C
Description:	Based on the review of facility records and interviews conducted with the facility staff, the Administrator failed to be responsible for the general administration and management of the facility and shall oversee the day-to-day operation of the facility. This shall include responsibility for: Ensuring that care is provided to residents in a manner that protects their health, safety, and well-being Evidence: Three days after admission a resident new to the facility left the facility without staff?s knowledge. The facility did not have staff records for the two facility direct care staff assigned supervision of the floor where the resident lived. An emergency preparedness plan was not implemented for the missing resident. Facility infection control is not being maintained. Several resident rooms were observed to be cluttered with clothing and other items. Approximately 15 containers of unlabeled Ensure was observed in a refrigerator in a resident?s room in the safe and secure environment. On 04/28/2022 during the approximate time of 8:00a.m and 1:00p.m the facility?s Record Temperature Chart document was noted to have the recorded food temperatures for the dinner time meal that was to be served for the day.
Plan of Correction:	FACILITY'S RESPONSE Retrain staff on missing person and resident emergencies Business Office Manager to do a complete audit of employee files and any missing documentation will be completed. In service employees on Infection Control and screening log upon entering the community. Resident rooms are being decluttered and families are being called to pick up excess items. Ensure removed. Family was informed that Ensure is to remain in the nursing station and administered per MD orders. Dining director to in service all cooks on the importance of accurate food temperatures. Dining Director and Executive Director to check log books food compliance
Standard #:	22VAC40-73-250-A
Description:	Based on the review of facility records and interviews conducted with the facility Administrator the facility failed to ensure that a record was established for each staff person. Evidence: Facility staff #s 6, 7 and 8 Facility staff #s 7 and 8- Documented date of hire unknown. Upon request during the review of facility records on 04/19, 28/2022 the facility did not submit for the inspector?s review documented evidence that a facility record had been created for staff #s 6, 7 and 8 that included a criminal records report and sworn disclosure statement, personal and social data (#s7 and 8) documentation of orientation and training, and credentials. The administrator did however submit a facility Leave Information document for the inspector?s review that notes facility staff #7 worked at the facility the week of 02/13/2022
Plan of Correction:	FACILITY'S RESPONSE- "Business Office Manager to do a complete audit of employee files and any missing documentation will be completed."
Standard #:	22VAC40-73-250-C
Description:	Based on the review of facility records and interviews conducted with the facility Administrator the facility failed to ensure that an original criminal record report was obtained. Evidence: Facility staff #6-Documented date of hire 01/13/2022 Facility staff #s 7 and 8- Documented date of hire unknown Upon request during the review of facility records on 04/19, 28/2022 the facility did not submit for the inspector?s review documented evidence that a criminal records report had been obtained prior to or since the staff?s documented and or date of hire.
Plan of Correction:	FACILITY'S RESPONSE- "Business Office Manager to do a complete audit of employee files and any missing documentation will be completed. "
Standard #:	22VAC40-73-250-D
Description:	Based on the review of facility records and interviews conducted with the facility Administrator the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and prior to coming in contact with residents submits the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Facility staff #1-Documented date of hire 02/15/2022 Facility staff #2-Documented date of hire-10/04/2019 Facility staff #6-Documented date of hire 01/13/2022 Facility staff #s 7 and 8: Documented date of hire unknown Upon request during the review of facility records on 04/19, 28/2022 the facility did not submit for the inspector?s review documented evidence that facility staff #s 1, 2, 6, 7 and 8 are free of tuberculosis in a communicable form.
Plan of Correction:	FACILITY'S RESPONSE- "Business Office Manager to do a complete audit of employee files and any missing documentation will be completed."
Standard #:	22VAC40-73-260-A
Description:	Based on the review of facility records and interviews conducted with facility Administrator the facility failed to ensure that each direct care staff member maintained current certification in first aid. Evidence: Facility staff #6-Documented date of hire 01/13/2022 Facility staff #s 7 and 8: Documented date of hire unknown. Upon request during the review of facility records on 04/19, 28/2022 the facility did not submit for the inspector?s review documented evidence that facility staff #s 6, 7 and 8 have obtained certification in first aid since their date of hire.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that residents? Individualized service plans were updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #5-Documented date of admission 04/12/2021 02/11/2022: The facility?s Physician Progress Note document noted that the resident was seen by the doctor due to the resident being more confused and that the resident is ?not oriented time or place?. 04/03/2022: Resident left the facility without staff?s knowledge that resulted in injury to the resident. 04/12/2022: Facility staff documented on the facility?s Progress Notes document that due to the resident?s continuous exit seeking behaviors and ?for the safety of the resident private sitters is necessary.? 05/27/2022: During the interview facility staff #10 stated that the resident does continue to exhibit exit seeking behaviors even with the 15 minutes resident checks conducted by staff and that the resident does need private sitters. The resident?s 06/30/2021 ISP was not updated to note the resident?s assessed need for a private sitter. The resident?s 04/28/2022 Individualized Service Plan (ISP) was also not updated to note that having a private sitter for the resident is an identified need.
Plan of Correction:	FACILITY'S RESPONSE- "Director of Nursing or Designee to conduct an audit of all Resident ISPs, Director of Nursing to review and oversee ISPs for accuracy of resident?s current needs."
Standard #:	22VAC40-73-460-C
Description:	Based on the review of facility records and interviews conducted with facility Administrator the facility failed to ensure that care is furnished in a way that fosters the independence of each resident and enables him to fulfill his potential. Evidence: Resident #1-Documented date of admission-02/15/2022 On 02/19/2022 at 2:20a.m; three days after admission the resident exited the building through a first floor side door. During interviews the facility Administrator said the door was not alarmed. At the time of the incident resident#1 lived on the first floor. The local police was not contacted until approximately 6 hours after the resident left the facility. Based on the review of facility records facility staff #s 6 and 7 were the only two facility staff assigned to the first floor of the facility. Upon request the facility did not submit documentation that a facility record had been created for the two staff members that were responsible for the supervision of resident #1. During interviews the facility Administrator stated that since this incident resident #1 has been placed on the facility?s safe and secure unit. However, upon request during the review of facility records and interviews conducted on 04/19, 28/2022 the facility Administrator did not submit for the inspector?s review documented evidence that prior to 02/19/2022 resident #1 exhibited behaviors since admission that required an assessment by an independent clinical psychologist or that noted that resident #1 had been diagnosed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Plan of Correction:	FACILITY RESPONSE- "Employees will be in serviced on missing person and resident emergencies. Business Office Manager to do a complete audit of employee files and any missing documentation will be completed. Resident has a diagnosis of dementia, resident?s MD completed required paperwork for the secure unit."
Standard #:	22VAC40-73-470-G
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that if a resident refuses medical attention, the facility assessed whether it can continue to meet the resident's needs. Evidence: Resident #5-Documented date of admission 04/12/2021 04/07/2021: Using the Uniform Assessment Instrument (UAI) facility staff assessed the resident as having appropriate behavior patterns and disoriented to time and situation some of the time. 02/11/2022: The facility?s Physician Progress Note document notes that resident #5 was being seen by the doctor due to concerns of being more confused. On 04/03/2022 the facility submitted a self-reported incident informing that without staff?s knowledge resident #5 ?walked out of the building and across the street at 1:50am per cameras and was returned about 3am.? Facility records noted that as a result of this incident the resident was also sent to a local hospital for emergency medical intervention and returned back to the facility the same day diagnosed with a head injury. 04/07/2022: Using the Uniform Assessment Instrument (UAI) facility staff reassessed the residents? behavior patterns as wandering/Passive - Weekly or more and also documented that all times resident #5 is disorientation to person, place and time. 04/12/2022: The facility?s Progress Notes document notes in part ?continued exit seeking behavior. Staff reports that resident continues to do this even with 15 minute safety checks in place. The resident?s doctor identified) also has been notified of the exit seeking behavior and recommends memory care at this time with the consent of the POA.? 05/27/2022: Facility staff #10 stated during the interview that the resident?s Power of Attorney?s (POA) continues to object to the resident being admitted to the facility?s? safe and secure environment therefore the resident continues to reside in the facility?s assisted living program. Facility staff #10 further stated that the resident continues to exhibit exit seeking behaviors and does need a private sitter as offered to the residents? POAs. . On 04/07/2022 the facility Administrator approved that resident #1 is not oriented to person, place and time, that the resident continues to exhibit exit seeking behaviors and that the resident continues to reside in the assisted living program. Upon request the facility did not submit documentation that an assessment by an independent clinical psychologist had determined whether resident #1 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger or protect his own safety and welfare and whether the resident?s needs can be met at the facility.
Plan of Correction:	FACILITY'S RESPONSE- "Director of Nursing or Designee will conduct an audit of all resident?s UAI and ensure that individual needs are addressed on the ISP"
Standard #:	22VAC40-73-990-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to implement procedures to be followed in the event that a resident is missing, including appropriate law-enforcement agency. Evidence: Resident #1-Documented date of admission 02/15/2022 The facility submitted a self-reported resident incident informing that without facility staff?s knowledge resident #1 left the facility on 02/19/2022 at 2:20a.m. The facility administrator also reported ?I (referring to herself) was notified at 6:45am and came into the building. I called the police and went to the strip mall the resident was found at.? The facility administrator stated during interviews that she arrived at the building around 8:00a.m or so and that no one had called the police prior to her arrival to the facility and that the resident was located within approximately 20 minutes of 911 call. During interviews the facility administrator stated that facility staff # 7 stated that she did not make a report to the local police because she did not know what to do. The facility Administrator also stated during interviews that the facility?s video system captured the resident leaving out of a side door of the facility. Based on emails submitted to the department regarding this incident and interviews conducted the facility did not make a report to the local police until approximately 6 hours after the resident left the building.
Plan of Correction:	FACILITY'S RESPONSE- "Employees will be in serviced on missing person and resident emergencies."