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: Nov. 6, 2023 and Nov. 9, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal An on-site renewal inspection was conducted on 11-6-23 (AR 08:05 a.m./Dep 16:15 p.m) The facility census was 33. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for three of five records reviewed. Evidence: 1. On 11-6-23, resident #1?s uniformed assessment instrument (UAI) dated 6-26-23 noted dressing need assessed as mechanical help/physical assistance. The ISP dated 7-28-23 did not identify the mechanical help. Bladder need assessed as greater than weekly. The ISP did not identify who would provide the services. The resident?s orientation assessed as disoriented some time to time and situation. The ISP did not who would provide the services. 2. Resident #2?s UAI dated 7-26-23 noted bathing and dressing need assessed as mechanical help. The ISP dated 8-29-23 did not identify the mechanical help. 3. Resident #5?s UAI dated 8-4-23 noted dressing, toileting and transferring need assessed as mechanical help. The ISP dated 9-13-23 did not identify the mechanical help. 4. Staff #1 acknowledged the residents? ISP did not include all assessed information.
Plan of Correction:	1. The Administrator updated ISPs for Residents #1, #2 and #5 by the date of the exit conference held on 11/9/2023. Resident #l's ISP was updated to identify who would provide help with changing incontinence products. Resident #2's ISP was updated with what type of mechanical help needed for bathing and dressing. Resident #S's ISP was updated with what type of mechanical help is needed for dressing, toileting, and transferring. 2. Administrator/designee will complete an audit of resident ISPs to ensure the method of mechanical help is noted for needs that require mechanical help. 3. Administrator/designee will educate ISP certified nurses on noting the method of mechanical help on the ISP for needs that require mechanical help. 4. Administrator/designee will audit 6 ISPs per week for 6 weeks to ensure residents' mechanical needs on ISPs have been updated with the method of mechanical help. 5. Corrective action will be completed by 12/31/2023.
Standard #:	22VAC40-73-970-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills for each shift in a quarter shall not be conducted in the same month. Evidence: 1. On 11-6-23, the facility fire and emergency evacuation drill documents determined the facility last fire drill conducted on the first shift was conducted on 4-18-23. Staff #1 acknowledged; the facility?s fire drill was not conducted on each shift in a quarter.
Plan of Correction:	1. A dayshift fire drill was conducted by the Director of Facilities the day after DSS survey on 11/7/2023 at 9:30am. 2. The Director of Facilities/designee will conduct an audit of the 2023 fire drills by 11/30/2023 to ensure fire drills are occurring on all shifts. 3. The Director of Facilities/designee will educate Maintenance Technicians on the regulations to conduct a fire drill on each shift over a quarter. 4. Administrator/designee will audit facility fire drills quarterly for 2 quarters to ensure each shift has been captured. 5. Corrective action will be completed by 3/31/2024