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: Aug. 30, 2022

Complaint Related: No

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: On 08/24/2022 beginning at approximately 11:17a.m until approximately 4:01p.m. and on 08/30/2022 beginning at approximately 11:17a.m until approximately 2:45p.m. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication Administration Pass Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 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 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) bloodborne pathogens regulations. Evidence: During observation of the 08/24/2022 mid-morning medication administration pass facility staff #4 did not sanitize the top of the medication cart before placing the resident?s uncovered glucose monitoring equipment on top of the cart.
Plan of Correction:	FACILITY RESPONSE: "Inservice the RMAs on best practices for infection control when performing glucose monitoring. Random checks will be performed during med passes by Director of Nursing or designee."
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 personal and social data to be maintained on staff and included in the staff record. Evidence: Upon request the facility did not submit for the inspector?s review documented evidence that a sworn disclosure statement was obtained for facility staff #1.
Plan of Correction:	FACILITY'S RESPONSE: "Employee file audit will be conducted to ensure every. Employee has a sworn disclosure statement by Business Office Manager or designee."
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 #2-Documented date of hire 06/03/2021 Facility staff #3-Documented date of hire 10/04/2019 Facility staff #4-Documented date of hire-03/23/2021 Upon request during the review of facility records the facility did not submit for the inspectors? review documented evidence that facility staff #s 2, 3 and 4 are free of tuberculosis in a communicable form
Plan of Correction:	FACILITY'S RESPONSE: "Employee file audit will be conducted to ensure every employee file has a date of hire and a TB screen."
Standard #:	22VAC40-73-320-B
Description:	Based on the review of facility records and interviews conducted with the facility staff, the facility failed to ensure that an annual risk assessment for tuberculosis (TB) evaluations are maintained on the residents. Evidence: Resident #1 Documented date of admission 02/05/2018 Documented date of last TB 06/21/2021 Upon request during the review of facility records the facility did not submit for the inspectors? review documented evidence that an annual risk assessment for tuberculosis completed for the resident
Plan of Correction:	FACILITY'S RESPONSE: "Resident file audit will be conducted to ensure annual TB forms are completed by Director of Nursing or designee."
Standard #:	22VAC40-73-550-C
Description:	Based on observation and interviews conducted with the facility staff, the facility failed to ensure that any resident of an assisted living facility has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia and this chapter. Evidence: 08/24/2022: As evidence by the photographs taken during the mid-morning medication administration pass facility staff #1 administered a resident?s insulin in the common area of the first floor with no barrier in place that provided privacy to the resident.
Plan of Correction:	FACILITY'S RESPONSE: "Inservice RMAs on best practices for providing privacy during insulin administration by Director of Nursing or designee."
Standard #:	22VAC40-73-550-G
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident or his legal representative or responsible individual Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: Resident #1-Documented date of admission 02/05/2018 The facility records submitted for review noted 05/11/2021 as the last documented date that the review of rights was reviewed with the resident.
Plan of Correction:	FACILITY RESPONSE: "Resident file audit will be conducted for annual resident rights and Activity Director or designee will ensure residents or families sign."
Standard #:	22VAC40-73-870-A
Description:	Based on observation the Administrator failed to ensure that the interior of all buildings is maintained in good repair and kept clean and free of rubbish. Evidence: As evidenced by the photographs taken and accompanied by the facility Administrator and Director of Nursing on 08/24, 30/2022 the following was observed in multiple resident rooms throughout the facility: Dark stains on ceiling tile. Multiple resident rooms and closets were observed to be cluttered with clothing and other items. -A used bowl with stains of food was left unattended in a residents? room. -A bag of residents? clothing was observed on the floor behind a chair. -Bedroom walls were stained -A residents? mattress and box spring covers were stained in some areas with what the Administrator described as remnants from the bedbug treatments. -A resident?s bedroom was observed to have a used bottle of Gatorade, an open container of Ensure, and a plastic water bottle that had a small amount of dark liquid was left unattended on the resident?s side table. -An unfolded and stained white blanket and a plunger was observed in a residents? bathroom on the floor under the toilet.
Plan of Correction:	Checklist is created to audit resident rooms on a regular basis and ensure they are maintained in good repair and kept free of rubbish."
Standard #:	22VAC40-73-870-B
Description:	Based on observation the facility failed to ensure that all buildings are free from foul, stale, and musty odors. Evidence: During the walk through of the physical plant accompanied by the DON a foul odor was noticed in multiple resident rooms on the third floor.
Plan of Correction:	FACILITY'S RESPONSE: "Inservice all housekeepers on cleaning and mopping best Practices to remove foul, stale and musty odors. Through Manager spot checks of rooms, they are to ensure rooms are Free of foul, stale and musty odors."
Standard #:	22VAC40-73-870-E
Description:	Based on observation the facility failed to ensure that all fixtures, and equipment, including furniture is kept clean and in good repair and condition. Evidence: During the walk through of the physical plant accompanied by the facility Administrator and the facility?s Director of Nursing the joint bathroom at room #329 did not have a functional light that came on when engaged by the inspector.
Plan of Correction:	FACILITY'S RESPONSE" " checklist has been created for managers to check and ensure that resident lights are working in room and bathroom."