Inspections by regulating agencies generally involved a sample of residents’ records as well as observations about operations and facilities.
For deficiencies or violations cited, Blue Ridge Rehab Center and Blue Ridge Manor were required to submit a plan explaining how they would correct each issue and prevent it from happening again.
BLUE RIDGE REHAB CENTER Inspection at Blue Ridge Rehab Center on Aug. 15, 2018 DEFICIENCIES
» Staff “failed to provide privacy dignity and respect” for two residents. Specifically, a complaint alleged that on July 30, 2018, a housekeeping staff member videoed two residents during a sexual contact in the dining room and then showed the video to several other staff members. The housekeeping staff member who videotaped the consensual sexual contact and several other staff members who were shown the video were all suspended pending the investigation. The housekeeping staff member “was terminated” as a result of the investigation, which determined the incident did happen.
Inspection at Blue Ridge Rehab Center on June 26-28, 2018
DEFICIENCIES» The facility’s emergency plan didn’t address procedures for staff to provide continuing care to residents in case of evacuation of the facility.
» Staff failed to respect the rights of one resident by failing to knock on a closed door prior to entering.
» Staff failed to ensure code status was correct for four residents. “Code status” refers to the level of medical interventions a patient wishes to have started if his or her breathing or heart stops.
» Staff failed to ensure a comprehensive assessment (called minimum data set) of six residents to identify functional capabilities and health problems.
» Staff failed to ensure that a nurse aide was included in the care planning process for one resident.
» Staff failed to provide fingernail care for one resident.
» Staff failed to ensure that a resident’s “indwelling Foley catheter tubing was not touching the floor.”
» Staff failed to maintain oxygen equipment in a clean and sanitary manner for two residents, and failed to ensure that oxygen was administered as ordered by the physician for one resident.
» Staff failed to assess and monitor a dialysis shunt for three residents.
» Staff failed to ensure that two residents were free from unnecessary psychotropic medications, which include such things as anti-psychotic, anti-depressant, anti-anxiety and hypnotic drugs.
» Staff failed to provide rehabilitative services for one resident.
» Staff documented a fall in the clinical record for one resident that occurred with a different resident.
» Facility failed to ensure its staff implemented appropriate infection-control measures for three residents.
Inspection at Blue Ridge Rehab Center on May 9-11, 2017DEFICIENCIES» Staff failed to obtain a Virginia State police criminal background check for one employee (within 30 days of employment).
» Staff “failed to ensure a clean, comfortable and homelike environment in the facilities.”
» Specifically, on May 9, 2017, the inspector entered the first floor of the facility and noted a pervasive odor of urine.
» On the third floor, the inspector observed five soiled ceiling tiles at the double doors entering the unit. The shower room had a pervasive odor of urine.
» “Rooms 357 and 351 had soiled privacy curtains. The privacy curtains were soiled with a brownish debris. Dead bugs were observed in the hallway overhead florescent lights at rooms 362 and 373. The chairs in the dining room were in poor repair. The chairs were torn and visibly soiled. The dark finish dining tables had the finish worn away, exposing a light wood color.... Six of the overhead florescent lights in the dining room had dead bugs in them,” the inspection report said.
» On the second floor on the North 2 Unit, the inspector saw dead bugs in the hallway overhead florescent lighting near rooms 255 and 261. The unit smelled of urine, and the shower room on the North 2 unit had four broken tiles. The shower chair was dirty and the back rest, which was a mesh material, appeared to be dry rotted and needed replacing. The shower stretcher, which was made of a mesh material, looked like it was dry rotted and needed replacing. The padding on the shower stretcher was cracked and peeling and needed replacing. The lower portion of the tiled walls and crevices where the walls met the floors were soiled with what appeared to be a dark brownish mildew.
» On the 2 South Unit, the inspector saw dead bugs in the hallway overhead florescent lighting near rooms 212 and 224.
» On the North 1 Unit, the shower chair in the shower room was dirty and the back rest, which was a mesh material appeared to be dry rotted and needed to be replaced. The shower stretcher, which was made of mesh material, appeared to be dry rotted and needed to be replace. The padding on the shower stretcher was cracked and peeling, needing to be replaced. The inspector saw broken tiles in the shower room. The lower part of the tiled walls and crevices where the walls met with the floors were soiled with what appeared to be dark brownish mildew. The unit smelled of urine, and there were soiled ceiling tiles in the hallway near the nurses’ station and near room 138.
» The 1 South Unit had a pervasive odor of urine. In the shower room, the shower chair was dirty and the back rest, which was a mesh material, appeared to be dry rotted and needed to be replaced. The padding on the shower stretcher was cracked and peeling, needing replacing. The inspector saw four broken tiles in the shower room. The lower portion of the tiled walls and crevices where the walls met the floors were soiled with what appeared to be dark brownish mildew. In the hallway near room 167, reddish brown debris soiled four ceiling tiles.
» Staff failed to code hospice status in the record for one resident.
» Staff failed to provide a care-planned fall intervention (fall mattress at bedside) for one resident at a high risk for major injuries from falls due to a previous history of falls.
» One resident received an extra, but unnecessary dose of an antibiotic.
» Staff failed to ensure timely physician visits for one resident.
» Staff failed to ensure the pharmacist completed a monthly drug regime review for one resident.
» Staff failed to ensure a complete and accurate clinical record for four residents.
BLUE RIDGE MANOR
Inspection at Blue Ridge Manor on May 16, 2019 VIOLATIONS
» “…The licensee failed to ensure that the department’s representative was afforded reasonable opportunity to inspect all of the facility’s books and records.” The Division of Licensing Programs had sent a letter to Blue Ridge requesting a copy of the current lease of the facility, updated personal qualifying information forms and all accounts payable for the licensure period beginning June 4, 2018. As of June 17, 2019, the information had not been received from the licensee.
» “…The facility failed to ensure that restraint training was completed at least annually for all direct care staff,” an inspection report said. According to a Centers for Medicare and Medicaid website, “Although the requirements describe the narrow instances when physical restraints may be used, growing evidence supports that physical restraints have a limited role in medical care.”
» The facility had too few staff to provide services to maintain the physical, mental and psychosocial well-being of each resident as determined by assessments and individualized service plans.
» Specifically, during April and May 2019, there were numerous nights where only two direct-care staff were scheduled for the 11 p.m. to 7 a.m. shift. Two staff people confirmed that schedule was correct and that was their current staffing pattern for that shift on many days.
» Four of the 38 residents living in the facility required two-person assists with activities of daily living.
» “On nights where only 2 direct care staff are scheduled, when both are required to be in a room to assist with a resident requiring 2 persons, no one would be left on the floor to assist any other resident who may require help,” the inspection report said.
» The facility failed to ensure that all required information was included on medication administration records for five residents.
» The name of the current on-site person in charge was not posted in a place in the facility that would be conspicuous to the residents and the public.
» The records of three residents contained an outdated resident agreement, which did not include information required by new regulations that were effective Feb. 1, 2018.
» The individualized service plan for one resident didn’t address that person’s identified need for fall precautions and no chicken or eggs with meals.
» The facility failed to ensure that medications were administered to 10 residents no later than one hour past the standard dosing schedule.
» The facility failed to ensure that several over-the-counter medications were labeled with a resident’s name.
» “…the facility failed to ensure that an inspection by the appropriate fire official was completed annually. The most recent fire inspection that was produced for review by the facility on the day of inspection was completed on 9/14/17. There was no documentation available for review to indicate that the facility has contacted the appropriate fire official to request that fire inspection be completed,” the inspection report said.
» “…the facility failed to ensure that at least a 48-hour supply of emergency drinking water was available on site at the facility…. The [licensing inspector] and staff person 7 located 4 five gallons of water, for a total of 20 gallons. Staff person 7 confirm[ed] this was the only emergency water supply. The industry standard recommendation from the Virginia Department of Emergency Management is 1 gallon of water per person per day. The census on the inspection day was 38; therefore, about 76 gallons should have been on site,” the inspection report said.
Inspection of Blue Ridge Manor on May 16, 2019
“The Piedmont Licensing Office received a complaint in regards to Blue Ridge Manor alleging that the facility has not paid rent in over a year and is currently operating without a license. The owner of the building is seeking an eviction,” an inspection report said.
The licensing inspector conducted an unannounced investigation at Blue Ridge Manor on May 16, reviewed current copies of vendor bills, accounts receivable for 2019 current and the facility 2019 fiscal budget. The inspector asked to review a current copy of the master tenant lease on the day of the inspection, but one was not produced.
» “… the licensee failed to have financial responsibility and solvency.” The landlord decided to terminate the lease because of default of the lease. Martinsville General District Court records showed a summons for a civil claim for eviction was issued on May 7, 2019 to BRVA Properties LLC and BRALFCO LLC. Court records indicated approximately $7,266,044.56 in delinquent rent and taxes were owed by the licensee.
» The licensing inspector was not given reasonable opportunity to inspect all of Blue Ridge Manor’s books and records. The administrator said the documents were unavailable and that she had reached out to the corporate office to request that the information be sent to the licensing inspector.
Complaint-related inspection of Blue Ridge Manor on Aug. 27, 2018VIOLATION» The facility failed to ensure that temperatures in all areas used by residents did not exceed 80 degrees Fahrenheit. On the day of the inspection, the common area of the right side of the facility was 81.5 degrees Fahrenheit at about 4:30 p.m.
Non-complaint-related inspection of Blue Ridge Manor on Aug. 27, 2018
VIOLATION» An as-needed medication prescribed for one resident was not available in the storage cart nor at the facility.
Inspection of Blue Ridge Manor July 2, 2018VIOLATIONS» The record for one resident showed the person was receiving hospice care but the individualized service plan did not have a detailed description of the services being provided by the hospice provider.
» The record for one resident had a physician’s order dated April 19, 2018 to discontinue a prescribed medication, but on the date of inspection on July 2, 2018, a bubble pack containing this medication for this resident was still in the medication cart. This was a repeat violation of the standard regarding disposal of discontinued medications, which was previously cited during an inspection on April 30, 2018.
» The inspector observed a medication for one resident in the medication cart, but the record for that resident did not contain a physician order for this medication and the facility staff was unable to locate a signed physician order during the inspection.
» A medication on a cart for one resident was not documented in the resident’s record. In addition, that same resident had a physician order dated April 19, 2018, for a different medication to be discontinued, but staff continued to administer the medication from May 1 through May 25, 2018.
» The record for one resident had a doctor’s order signed Aug. 9, 2017 for a number of medications as needed, but on July 2, 2018, the inspector noted that none of these medications were available, properly labeled for that resident or properly stored at the facility.
Inspection of Blue Ridge Manor April 30, 2018VIOLATIONS» Blue Ridge Manor failed to obtain, in writing, information on the type and frequency of the services to be delivered to one resident by private duty personnel.
» The facility failed to obtain, in writing, the results of a risk assessment documenting the absence of tuberculosis for three staff members within seven days prior to their first day at work there.
» The personal/social data forms for two residents were incomplete and the personal/social data forms for those two residents and three other residents had not been updated to include any known allergies for the residents.
» Required signatures when individualized service plans were updated or reviewed were lacking from two residents’ plans.
» Blue Ridge Manor failed to ensure prescriptions were filled in order to avoid missed doses for two residents. Specifically, one resident missed the prescribed doses of a medication on the morning of April 28 and the evenings of April 20-April 23, 2018 as the medication was not available on site. A different resident had a physician’s order for Ensure supplement twice daily but this supplement was not in the facility on the day of the inspection.
» Orders for as-needed medications for two residents did not include symptoms that indicated the use of the medication or directions as to what to do if symptoms persist.
» The inspector observed two instances when personal cleaning supplies or other hazardous materials were not in an out-of-sight place in resident rooms.
» The facility failed to ensure that furnishings, fixtures and equipment were kept in good repair. Specifically, vanities in four rooms were damaged. Upholstery was peeling off the seat and arms of a chair at a desk near the snack kitchenette.
» The facility did not conduct a fire drill during March 2018.
Inspection of Blue Ridge Manor Feb. 13 2018VIOLATIONS» One staff member who was hired on Dec. 15, 2017, had not been trained in dealing with aggressive residents.
» The records of three residents did not address how Blue Ridge Manor will ensure that they are not exposed to medications or foods that they have known allergies to.
» The menu posted for the current week on Units 1 and 2 was outdated.
» The record of one resident did not list the resident’s food allergies.
» Staff failed to ensure that a fluid-restriction diet was being served to one patient according to a physician’s order.
» A medication was not given to one resident as ordered on Feb. 11-Feb. 13, 2018, because it was not available on site, and a medication for a different resident was not given several days as ordered because it was not available on site.
» One medication cart had several packets of a medication lying loose in the cart without a prescription label.
» Staff failed to administer a medication to a resident in accordance with a doctor’s instructions on Feb. 9, 2018.
» The results of physician-ordered blood pressure and pulse checks daily for one patient were not documented one day. The results of a physician-ordered blood sugar check twice a week for a different patient were not documented one day.
» There was not documentation that two residents received doses of certain medication on Feb. 9.
» Records for two residents didn’t have start dates documented for the physician order for half rails to aid in bed mobility and positioning.
Blue Ridge Manor inspection on Nov. 20, 2017No violations were cited.
Paul Collins is a reporter for the Martinsville Bulletin. Contact him at 276-638-8801, ext. 236.
Paul Collins is a reporter for the Martinsville Bulletin. Contact him at 276-638-8801, ext. 236.
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