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. 16, 2022 , Dec. 8, 2022 and Dec. 12, 2022

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

Comments:

Type of inspection: Monitoring An unannounced mandated monitoring inspection was conducted on-site on 11-16-22 (ar 07:43 a.m./dep 7:23 p.m.) The facility census was 33. A tour of the facility was conducted, medication pass observation with staff, staff and resident records reviewed, emergency preparedness items reviewed (water, fire drill, emergency preparedness and first aid kits check conducted). An exit meeting conducted with the administrator and team and violations reviewed. Request for additional documents made. The Acknowledgement of Inspection form was signed and left at the facility. A final 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 #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure its infection control program was implemented. Evidence: 1. On 11-16-22 during the medication pass observation with staff #7, resident #4?s blood sugar glucometer instrument was not labeled. 2. Staff #7 acknowledged the aforementioned resident?s glucometer was not labeled.
Plan of Correction:	1. Resident #4?s blood sugar glucometer was immediately labeled on 11/16/22 by staff #7 with the resident?s name. 2. Nurse Manager or designee will complete a 100% audit of all current residents using glucometers to ensure that they are appropriately labeled. 3. Nurse Manager/designee will educate the staff on ensuring all residents who have glucometers that the device itself is labeled. Staff will also be educated on the admission form and process to include the use of medical devices being labeled appropriately. An additional line item will be updated in the admission form and process to include use of medical devices needing to be labeled correctly. 4. Nurse Manager/designee will audit med/treatment carts weekly for four weeks to ensure all glucometers are properly labeled. The results of the audit will be reviewed at the QAPI meeting. 5. All corrected actions were completed on 11/16/22.
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge, as provided per the regulation, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 11-16-22, the inspector did not see the posting of the staff person in charge upon arrival. Staff #6 and was inquired as to who was in charge as it was not posted in the foyer area. The area near bulletin board near the nursing station was checked. There was no listing posted on the bulletin board. Staff #7 was also asked where the staff person in charge information was posted. The information was not available when the inspector arrived on the morning of 11-16-22. 2. Staff #1 #6 and #7 acknowledged the staff person in charge posting was not available as required.
Plan of Correction:	1. Nurse Manager immediately posted on 11/16/22 the staff person in charge for public viewing. 2. Facility has been educated by the Administrator on the requirement of the posting of the foyer area of the staff person in charge. 3. Nurse and/or designee will educate the staff about the requirement that the staff person in charge be posted for public viewing on a daily basis. The form will be placed on a poster for view. 4. Nurse Manager and/or their designee will audit 3 times per week for 4 weeks to ensure that the appropriate person in charge signage is posted. The results of the audits will be reported at the QAPI meeting. 5. All corrected actions will be completed by 01/25/23
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure admit or retain individuals with any prohibitive conditions or care needs. Evidence: 1. On 11-16-22, record with staff #3 and #4, resident #1?s November 2022 medication administration record (MAR) documented resident is prescribed Ativan, physician order dated 5-5-22. The record did not include documentation of a psychotropic treatment plan. 2. Staff #3 acknowledged the aforementioned resident?s record did not include a treatment plan for the psychotropic medication.
Plan of Correction:	1. Resident #1 had a Psychotropic treatment plan created on 05/05/22 by nurse manager with review provided by the facility practitioner on 05/05/22. Hard Chart copy was uploaded to EMR and reflects on resident #1 ISP 12/16/22 2. A 100% audit of all residents prescribed psychotropic medications will be completed to ensure that each resident has a Psychotropic treatment plan in place. 3. Nurse Manager and/or their designee will educate all clinical staff on the requirement that each resident receiving a Psychotropic medication must have a treatment plan. 4. The Nurse Manager and/or their designee will complete weekly audits of 4 residents on psychotropic medications for treatment plans times for 4 weeks. The results of the audits will be reported at the QAPI meeting. 5. Corrective action will be completed by 01/25/23
Standard #:	22VAC40-73-440-K
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the uniform assessment instrument (UAI) was completed as required. Evidence: 1. On 11-16-22, residents? record review conducted with staff #4, resident #1?s UAI dated 7-26-22 did not include the signature and date of the second reviewer. 2. Resident #3?s UAI dated 11-4-2 did not include the signature and date of the second reviewer. 3. Staff #4 acknowledged the aforementioned residents? UAIs did not include the required documentation.
Plan of Correction:	1. Resident #1 and Resident #3?s UAIs were updated by Staff # 1 on 12/16/22 to include the signature of the second reviewer. 2. Nurse Manager/ designee will conduct a100% audit of all resident?s UAI and ISPs to ensure the appropriate signatures are listed on them. 3. Nurse Manager and/or designee will educate clinical staff on the requirement that a second UAI certified employee must sign off on the resident?s UAI. 4. Facility Administrator/designee will conduct a weekly audit on all newly completed UAIs to ensure that the appropriate signatures are noted. The results of the audit will be reported to the QAPI meeting. 5. Corrective action will be completed by 01/25/23
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 five of six records reviewed. Evidence: 1. On 11-16-22, resident record reviewed with staff #4, resident #1?s uniform assessment instrument (UAI) dated 7-26-22 documented toileting need assessed as human help/physical assistance. The resident?s ISP dated 7-26-22 documented toileting as mechanical help only. Resident assessed as disoriented to time- sometime. The services did not include what staff should do if the family was not available upon calling. 2. Resident #3?s UAI dated 11-4-22 documented toileting and transferring need assessed as mechanical help. The ISP dated 11-3-22 documented no help needed. Stairclimbing assessed as mechanical help. This assessed need was not documented on the ISP. Bladder assessed as incontinent less than weekly, however, the ISP documented no help needed. 3. Resident #4?s UAI dated 10-23-22 documented stairclimbing as mechanical help. The ISP dated 10-24-22 did not include this assessed need. Walking assessed as mechanical help. The resident uses a cane, this mechanical device was not documented on the ISP. Orientation assessed as disoriented some time to situation. The ISP did not include what staff should do to address this assessed need. 4. Resident #5?s UAI dated 8-22-22 documented disoriented in all spheres. For time orientation, the plan did not state what staff would do if the family was not available when called. 5. Resident #6?s UAI dated 11-10-22 documented stairclimbing as mechanical help. The ISP dated 11-10-22 did not include this assessed need. 6. Staff #4 acknowledged the aforementioned residents? ISPs did not include all assessed needs.
Plan of Correction:	1. Nurse manager reviewed and updated the UAIs and ISPs of resident #1, #3, #4, #5, #6 to reflect service needs on 12/16/22. 2. Nurse manager and/or designee will conduct a 100% audit of all resident UAI and ISPs to ensure that the service needs of the resident are accurately represented on both. 3. Nurse manager/ and/or designee will educate administrative/clinical staff (who updates the UAI/ISPs) on the requirement for the UAI and ISPs to accurately reflect the service needs of the resident. 4. Nurse manager and/or designee will audit five resident charts weekly for UAI and ISP review times 4weeks. The results of the audits will be reported to the QAPI meeting. 5. Corrective action will be completed by 01/25/23
Standard #:	22VAC40-73-680-M
Description:	Based on record reviewed, observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 11-16-22, during the medication pass observation with staff #7, resident #4?s PRN nasal spray was not available. 2. Staff #7 acknowledged the aforementioned resident?s PRN nasal spray was not available.
Plan of Correction:	1. Nurse manager immediately ordered resident #4s PRN nasal spray from the appropriate pharmacy which, was delivered on 12/17/22. 2. Nurse and/or designee will conduct an audit of all resident PRN medications to ensure that the medications are present on campus and available to give to the resident if needed. 3. Nurse manager and/or designee will educate all clinical staff on the requirement that PRN medication be available on campus to provide to residents as needed. 4. Nurse manager and/or designee will conduct a weekly PRN medication inventory review for 4 weeks. The results of the audit will be reported to the QAPI meeting. 5. Corrective action will be completed by 01/25/23