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: July 24, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/24/2024 ( arrival 10:23am/ departure 12:51pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/13/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but 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. 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 Darunda Flint, Licensing Inspector at (757)807-9731 or by email at Darunda.a.flint@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview with staff, the facility failed to ensure the physician's or other prescriber's oral orders were reviewed and signed by a prescriber within 14 days. Evidence: 1. Resident #1 had the following verbal order: Methylprednisolone Oral Tablet Therapy Pack 4 Mg (ordered 06/10/2024). There was no order signed by a physician or prescriber within 14 days of the verbal order in the resident #1?s record. 2. Staff #1 acknowledged that there was no signed physician or prescriber?s order in resident #1?s record.
Plan of Correction:	1. Resident #1s verbal order for Methylprednisolone was signed by the provider on 6/6/24. 2. AL Director/Designee reviewed all verbal orders to confirm they were reviewed and signed by the physician. 3. AL Director/Designee will educate the clinical staff on ensuring that providers oral orders are reviewed and signed by the provider within 14 days. 4. AL Director/Designee will audit two residents? orders weekly for eight weeks to ensure that all oral orders are reviewed and signed by physician within 14 days. The results of the audit will be reported at the QA meeting for evaluation and compliance. 5. All corrective actions will be completed by 9/30/3034.
Standard #:	22VAC40-73-680-J
Description:	Based on record review and staff interview, the facility failed to ensure that in the event of an adverse drug reaction or a medication error, the medication administration staff shall document actions taken in the resident?s record. Evidence: 1. On 06/13/2024,the licensing inspector received an emailed initial self-report from staff #1 which indicated that medication errors occurred at the facility on 06/10/2024, 06/11/2024, and 06/12/2024. The report further stated that resident #1 received an order for a Methylprednisolone Oral Tablet Therapy Pack and was administered the medication incorrectly for three days. There was no documentation of the medication errors in resident #1?s record, actions in response to the error, or documentation of physician or family notification of error in resident #1?s record. 2. Staff #1 acknowledged that staff failed to document the medication error and subsequent actions taken in the record for resident #1.
Plan of Correction:	1. Staff #1 placed a late entry note in the EMR regarding actions taken in response to the medication error and documented notification of MD and responsible party on 8/29/24. 2. All residents who were on glucocorticoids will be audited by the AL Director or designee to ensure correct administration orders are in place. 3. Educator/designee will educate staff #1 and other clinical staff that any adverse drug reactions or medication errors steps taken should be documented in the EMR. 4. AL Director/designee will audit one resident weekly for eight weeks who take glucocorticoid medication to ensure correct administration orders are in place. The results of the audit will be reported at the QA meeting for evaluation and compliance. 5. All corrective actions will be completed by 9/30/24