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:

Complaint Related: No

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