VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Blue Ridge Senior Living
12411 Gayton Road
Richmond, VA 23238
(804) 741-9494

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Aug. 31, 2023 and Sept. 8, 2023

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: 08/31/2023 approximate time 10:29am. -1:44pm. On 09/08/2023 approximate time 9:05am.-2:00p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 95 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 08/31/2023 and 09/08/2023 Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication administration pass observed on 08/31/2023. Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that prior to admission to a safe, secure environment an assessment was conducted for a resident. Evidence: Resident #9 The resident?s 05/20/2022 Assessment of Serious Cognitive Impairment document that was submitted for the inspector?s review is blank in the under the heading Behavior/Psychomotor
Plan of Correction:	FACILITY'S RESPONSE: "All new admissions will have an assessment of serious cognitive impairment upon admission to the facility and any residents who may need to move to a safe and secure environment will have a new updated assessment of serious cognitive impairment prior to the transition to the safe and secure environment."
Standard #:	22VAC40-73-70-A
Description:	Based on the review of facility records the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: Resident #9 The facility did not submit a report to the regional licensing office of the incident on 05/23/2023 when the resident ingested another resident?s medication.
Plan of Correction:	FACILITY'S RESPONSE: "All incident reports that affect the safety and welfare of the resident will be submitted within 24 hours of the incident per the standards for assisted living. The ED or designee will send these reports to the licensing inspector timely"
Standard #:	22VAC40-73-270-1
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the required training for staff in an assisted living facility that accept, or have in care, residents who are or who may be aggressive or restrained was obtained. Evidence: Staff #s 1-5 The staff training records that were submitted for the inspector?s review did not document that facility staff had received aggressive resident training. Interviews with the facility Administrator and the facility self-reported incidents to the department identified incidents of aggressive behaviors regarding resident #s 7, 8, 9.
Plan of Correction:	FACILITY'S RESPONSE: "All staff were trained in aggressive resident training on 10/25/23. All new staff will have aggressive resident training during orientation by the ED or designee."
Standard #:	22VAC40-73-340-B
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that the administrator or his designee documented that the individual's psychosocial and behavioral history were reviewed and used to help determine the appropriateness of the admission. Resident #7 Facility records revealed that the resident was admitted to the facility on 01/19/2022 from a state long term care facility. On 04/18/2023 resident #7 was transferred to the facility?s safe and secure environment. Upon request the facility did not submit for the inspector?s review documented evidence that the resident?s psychosocial and behavioral history was reviewed and used to help determine the appropriateness of the admission.
Plan of Correction:	FACILITY'S RESPONSE: "All prospects will be screened by the DON or ED prior to admission ensuring that the prospects needs can be met at the community level. Prior to admission residents medications and medical history will be reviewed and a determination will be made prior to acceptance into the community."
Standard #:	22VAC40-73-440-H
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that a reassessment due to a significant change in the resident's condition, using the UAI, was utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: The resident?s UAI that was submitted for the inspector?s review on 09/08/2023 noted that the facility reassessed the resident on 08/05/2023 as being oriented in all spheres but the resident resides in the safe and secure environment of the facility effective 08/05/2021. Upon request the facility did not submit for the inspector?s review documented evidence that resident #s 3 and 4 had been reassessed due to significant changes in the residents condition. Resident #3-Documented date of admission 03/01/2021 The facility assessed the resident on 02/09/2023 as needing no help with eating/feeding. The facility?s progress notes document revealed an 08/09/2023 late entry that notes the resident to need assistance with all of her activities of daily living (ADLs). Resident #4-Documented date of admission 03/26/2021
Plan of Correction:	FACILITY'S RESPONSE: "All residents needs will be noted on the ISP and any new orders or need changes will be added to the ISP to ensure staff are aware of the current needs of the residents."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the individualized service plans (ISP) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #1-Documented date of admission 05/15/2021 The resident?s 07/24/2023 ISP did not include the need for a for speech-language pathologist evaluation as recommended by the 05/18/2023 dietician report. Resident #2-Doumented date of admission 11/18/2022 The resident?s 06/16/2023 ISP that was submitted for the inspector?s review did not include the need for the resident to have a mechanical soft diet. Resident #3-Documented date of admission 03/01/2021 The resident?s 01/16/2023 ISP that was submitted for the inspector?s review did not include a plan to address the resident?s weight loss as noted on the 08/28/2023 dietician report. Resident #5-documented date of admission 09/29/2018 The resident?s ISP is not documented to identify the need for an evaluation to determine the resident?s possible diet upgrade as noted on the 05/18 and 08/31/2023 dietician report. Resident #7-Documented date of admission 01/19/2022 The resident?s 04/18/2023 UAI notes that a psychiatric or psychological evaluation is needed but the resident?s 04/18/2023 ISP is not documented to note such nor does the ISP document a plan for staff to implement to address the resident?s abusive, disruptive, aggressive behavior. Resident #8- Documented date of admission 03/25/2021 The inspector observed the resident on 08/31/2023 stroking the lower back of an activity assistant during an activity. The facility Administrator stated during interviews that the residents? behavior is inappropriate and that he has a habit of attempting to hug and kiss other individuals. The resident?s 06/02/2023 ISP is not documented to identify a plan of care for staff to implement to address the resident?s inappropriate behavior. Upon request the facility did not submit for the inspector?s review documented evidence that ISPs for resident #s 1, 2, 3, 5, 7, and 8 had been updated based on their individual assessed needs.
Plan of Correction:	FACILITY'S RESPONSE: "All ISP?s that were reviewed by the licensing inspector have been reviewed and corrected. ISP?a will be completed by the DON and reviewed with the residents and/or POA as well. All orders will be added and any changes will be noted. "
Standard #:	22VAC40-73-460-A
Description:	Based on the review of facility records and interviews conducted the facility failed to assume general responsibility for the health, safety, and well-being of all residents. EVIDENCE: Resident #9. Documented date of admission 12/02/2022 The resident resides in the safe and secure environment of the facility. Facility progress notes document that was submitted for the inspectors? review contained documentation that revealed that the facility was aware that resident #9 had behavioral disorders that caused, or continue to cause, concern for the health, safety, or welfare of either the resident or others who could be placed at risk of harm: 05/23/2023 facility staff documented that the resident snatched medications belonging to another resident from facility medication aide and ingested them. Refused to spit out. The resident?s physician documented that staff to monitor for bleeding as the resident took Eliquis. 05/25/2023 facility staff documented that the resident has a pack of cigarettes and staff could not retrieve them. 08/13/2023-Facility staff documented that the resident is exit seeking. 08/31/2023- Facility staff documented that the resident hit staff in the face with water pitcher from the medication cart. The staff member was taken to a local medical clinic for an eval of redness under left eye. 08 /29/2023- Facility staff documented that the resident drank paint water and was digging through trash cans. The facility assessed the resident on 11/16/2022 as abusive, aggressive, and disruptive weekly or more; noting that at times the resident is verbally aggressive towards staff and that the resident is disoriented to place and time; some of the time. The assessments also note that the resident is not in need of a psychiatric or psychological evaluation. Facility staff documented that the resident engaged in repeated and increased acts of aggression but did not submit for the inspectors? review documented evidence that (1) facility staff understood the assessment process for placement, (2) that resident #3 had been reassessed to determine appropriateness of placement or an alternative placement, (3) that direct care staff were provided guidance on implementing a plan for increased supervision (4) that a structured plan of care had been developed that established guidance for direct care staff to implement that would ensure that potential and continued aggressive behaviors had no negative impact on the health, safety and well-being of the resident; other residents as well as facility staff.
Plan of Correction:	FACILITY'S RESPONSE: " All residents are now being properly screened and assessed prior to admission. Residents from mental health facilities and state run hospitals will be assessed by the DON and ED prior to admission via in person and through all available documentation regarding behaviors and medical diagnoses"
Standard #:	22VAC40-73-620-B
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the oversight of the special diets specified in subsection A of this section was on site and included all of the required elements. Evidence: The facility?s 05/18/2023 and 08/28/2023 Assisted Living Facility Therapeutic Diet Report that was submitted for the inspector?s review revealed the following: Resident #1 The report for 05/18/2023 and 08/28/2023 both note in part ?Res requesting diet upgrade to Regular w/chopped meats. Likes sandwiches at meals and at times is denied to diet rx. Rec SLP eval for request to upgrade diet.? Resident #2- The 05/18/2023 dietician reports note that the resident receives a mechanical soft diet when the physician?s order is for a regular diet. The resident?s 08/28/2023 dietician report notes in part to change the resident?s diet to regular. Upon request the facility did not submit for the inspector?s review documented evidence of the action taken in response to the dietician?s recommendations.
Plan of Correction:	FACILITY'S RESPONSE: "All recurring and new diet orders will be followed through on and noted on the residents ISP. All documentation will be noted in the residents file."
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation the facility failed to ensure that the medication storage area was locked. Evidence: The inspector observed during the physical plant walk through on 09/08/2023 that the medication cart on the first floor of the facility was not locked and the door leading into the medication room was also not locked. The facility Administrator was present and observed the same including that the locked medication cart contained multiple bubble packs and bottles of medications for facility residents.
Plan of Correction:	FACILITY'S RESPONSE: "All med carts will be securely locked and held in the locked nursing station when not in use by the LPN or RMA."
Standard #:	22VAC40-73-690-F
Description:	Based on the review of facility records and interviews conducted the facility failed to maintain in the facility files and resident records for at least two years, documentation of any specific recommendations from the medication review regarding a particular resident. Evidence: Resident #s1, 2, 4, 6, 7,8, 9 and 10. The facility?s 04/01/2023 and 04/25/2023 Medication Regimen Review report that was submitted for the inspector?s review notes in part ?The following is a list of residents which were reviewed during the consultant?s pharmacist?s visit but did not require any recommendations.? The report identifies a total of 35 residents. The Medication Regimen Review report also notes that 43 reports were written to physicians and 18 reports were written to nursing but does not identify the residents that these written reports are referencing. Resident #s 1,2 4, 6, 7, 8, 9 and 10 are not identified on the 04/01/2023 and 04/25/2023 Medication Regimen Review report and did not have documented evidence in each of their records that noted a medication review had been conducted. The Administrator confirmed that the pharmacy reviews were not available in each residents? record. The facility did not submit upon request while onsite at the facility on 08/31/2023 and 09/08/2023 documented evidence that the recommendations and follow-ups from the facility?s 04/01/2023 and 04/25/2023 Medication Regimen Review that are specific to residents were conducted and maintained in the resident?s record.
Plan of Correction:	FACILITY'S RESPONSE: "Pharmacy reviews and all other required documentation will be placed in the residents files. Master copies will be held in the Administrators office for licensing reviews"