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: Sept. 25, 2024

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: 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: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: A morning medication administration pass observed on 09/25/2024 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 #:	22VAC40-73-250-C
Description:	Based on the review of facility records the facility failed to ensure that Personal and social data was maintained on staff and included in the staff record. Evidence: Staff #3-Documented date of hire-08/02/2024 The review of facility records with the facility Administrator revealed that revealed that an original criminal record report was not obtained for staff #3.
Plan of Correction:	FACILITY'S RESPONSE: "Blue Ridge Senior Living will comply with the regulation for background checks to include all new staff as well as those that are rehired regardless of time period in between employment periods"
Standard #:	22VAC40-73-320-A
Description:	Based on the review of facility records the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain all of the required elements. Evidence: Resident #2-Documented date of admission 03/26/2021 The review of facility records with the facility Administrator revealed that the 03/23/2021 physical examination report for resident #2 did not include documentation of the residents? diagnosis or significant problems; recommendations for care including medication, diet, and therapy and whether the resident is capable of self-administering medication.
Plan of Correction:	FACILITY'S RESPONSE: "Blue Ridge has developed a plan to check all admission paperwork on all residents. All residents files will undergo a quality assurance check to ensure that regardless of the time of admission that all paperwork required for admission will be complete and accurate"
Standard #:	22VAC40-73-325-B
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that a fall risk rating was reviewed and updated after a fall. Evidence: Resident #2-Documented date of admission 03/26/2021 The review of facility records with the facility Administrator revealed that the resident had falls on 08/10/2024 and 08/25/2024 but did not conduct a fall risk rating after each of these falls.
Plan of Correction:	FACILITY'S RESPONSE: "Blue Ridge will add to our qa checklist that all falls have been assessed and scored a rating with interventions to ensure safety of our residents"