Current Inspector:
Angela Rodgers-Reaves
(804) 662-9774
Inspection Date:
June 21, 2024
and
July 10, 2024
Complaint Related:
No
Comments:
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: 06/21/2024 approximate time 9:30-12:31p.m On 07/10/2024 approximate time 10:13a.m-1:19p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 06/14/2024 regarding allegations in the area of resident care and related services.
Number of residents present at the facility at the beginning of the inspection: 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 staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: The inspector attempted an interview with the resident but did interview the resident?s power of attorney.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all area(s) of non-compliance with standard(s) or law.
A violation notice was issued. 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
Based on the review of facility records and staff interviews the facility failed to ensure that medications were administered as prescribed by a valid order from a physician or other prescriber.
Evidence:
Resident #1
The review of the resident?s March 2024 medication administration (MAR) record that was submitted for the inspector?s review on 07/10/2024 revealed that at 9:00 a.m. on March 21-31, 2024, and at 1:00p.m. on March 1-19, 2024, facility staff administered 0.5mg of the medication Lorazepam to resident #1 without a physician?s order.
The review of the resident?s June 2024 medication administration record (MAR) that was submitted for the inspector?s review on 06/21/2024 revealed that at 9:00 a.m. on June 4, 7, 12,13, 2024, facility staff administered 0.5mg of the medication Lorazepam to resident #1 without a physician?s order.
Upon request the facility Administrator did not submit for the inspector?s review the resident?s March and June 2024 physician?s orders for the administration of the medication Lorazepam on the documented dates and times.
Plan of Correction:
FACILITY'S RESPONSE: "Blue Ridge Senior Living strives to meet all resident needs including daily care and administration of medications. This was an input error in the EMAR. The resident was not given the incorrect dose in March and in June this was caught immediately. Going forward we will review all new orders/prescriptions prior to the input into the EMAR system. Pharmacy will also question any new orders/prescriptions prior to filling and sending to the community. All requested paperwork was provided to the inspector at the time of the exit interview"
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
Find this content at:
http://www.dss.virginia.gov/facility/search/alf.cgi