Inspection Reports for Blue Ridge Christian Homes – Raphine
85 Beulah Dr, Raphine, VA 24472 , VA, 24472
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-03-24 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection, primarily concerning medication administration orders, staff authorization to administer medications, and medication administration record documentation.
Complaint Details
The complaint was received on 2025-03-24 regarding resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure physician or other prescriber orders for all medications included all required information such as resident name, date, drug name, route, dosage, strength, frequency, and indication. |
| Facility failed to ensure staff administering medications were authorized and licensed or registered as medication aides as required by Virginia law. |
| Facility failed to ensure medications were removed from pharmacy containers and administered by properly licensed or registered staff. |
| Medication administration records (MAR) did not include all required components and contained documentation errors regarding medication administration times and dates. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Deficiencies: 0
Jan 7, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with the criminal history record report standards.
Findings
The inspection found no violations with applicable standards or laws. No resident records were reviewed, and two staff records were reviewed with one staff interview conducted.
Report Facts
Number of resident records reviewed: 0
Number of staff records reviewed: 2
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 16
Deficiencies: 8
Nov 13, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the continued licensing of the assisted living facility.
Findings
The inspection identified multiple violations related to staff training requirements, resident care documentation, and employee background checks. The facility was found non-compliant with several regulatory standards and was issued a violation notice with opportunities to submit plans of correction.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure direct care staff attended six hours of training in working with individuals who have cognitive impairments within four months of employment. |
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to ensure at least two hours of infection control training and four hours of training related to residents' mental impairments within the required annual training. |
| Facility failed to ensure direct care staff received first aid certification within 60 days of employment. |
| Facility failed to ensure a written fall risk rating was completed by the time the comprehensive individualized service plan was completed for residents meeting assisted living criteria. |
| Facility failed to ensure the uniform assessment instrument (UAI) was completed as required for private pay individuals. |
| Facility failed to ensure oversight of special diets by a dietitian or nutritionist at least every six months for residents with special diets. |
| Facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Number of residents present: 16
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Deficiencies: 1
Jan 17, 2024
Visit Reason
The inspection was a monitoring visit conducted via phone call to review compliance with personnel standards, specifically regarding the facility's acting administrator status.
Findings
The facility was found to be non-compliant with the standard 22VAC40-73-150-B-6 because it has been operated by an acting administrator for longer than 150 days without completing required licensing steps.
Deficiencies (1)
| Description |
|---|
| Facility is currently being operated by an acting administrator for longer than 150 days without completing required registration and licensing steps. |
Report Facts
Days acting administrator exceeded: 150
Timeframe to become licensed administrator: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person 1 | Acting Administrator | Named in finding regarding acting administrator status and plan of correction |
| Jennifer Stokes | Licensing Inspector | Conducted the inspection and communicated findings |
Inspection Report
Renewal
Census: 14
Deficiencies: 5
Dec 13, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found multiple violations related to staff tuberculosis screening, resident admission procedures, annual review of resident rights, timely physician order signatures, and inclusion of Do Not Resuscitate orders in individualized service plans. The facility was found non-compliant in these areas and issued a violation notice.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure each staff person annually submits tuberculosis risk assessment screening. |
| Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender. |
| Facility failed to ensure annual review of residents' rights and responsibilities with each resident or legal representative. |
| Facility failed to ensure physician's or prescriber's oral orders are reviewed and signed within 14 days. |
| Facility failed to include Do Not Resuscitate (DNR) orders in the individualized service plan for a resident. |
Report Facts
Residents present: 14
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 3
Inspection Report
Monitoring
Deficiencies: 1
Jul 27, 2023
Visit Reason
The inspection was a monitoring visit conducted via phone call to assess compliance with personnel standards, specifically regarding the administrator of record.
Findings
The facility was found non-compliant for failing to have an administrator of record since June 30, 2023, as confirmed by collateral interviews and communication with the facility.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure to have an administrator of record. |
Inspection Report
Monitoring
Deficiencies: 0
Jan 10, 2023
Visit Reason
This inspection was conducted to follow-up on high-risk violations cited during the facility's renewal inspection conducted on 2022-12-06.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or law.
Inspection Report
Renewal
Census: 16
Deficiencies: 12
Dec 6, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to staff training, certification, resident record documentation, medication administration, emergency preparedness, and criminal history checks. The facility was found non-compliant with several regulatory standards and was required to submit plans of correction.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure a direct care staff person attended six hours of training in working with individuals who have a cognitive impairment within four months of employment. |
| Facility failed to ensure orientation for new staff was completed within the first 7 working days of employment. |
| Facility failed to obtain a copy of certification or documentation indicating staff met requirements to be employed as direct care staff. |
| Facility failed to ensure direct care staff received 18 hours of training annually. |
| Facility failed to ensure a direct care staff member obtained first aid certification within the first 60 days of employment. |
| Facility failed to ensure physical examinations were obtained within 30 days prior to admission. |
| Facility failed to document that residents were not registered sex offenders prior to admission. |
| Facility failed to ensure identified needs were addressed on individualized service plans (ISPs). |
| Facility failed to ensure an individualized service plan for a resident was signed by the resident or legal representative. |
| Facility failed to ensure medication was administered in accordance with physician's instructions. |
| Facility failed to ensure a semi-annual review of the emergency preparedness and response plan was conducted with residents. |
| Facility failed to ensure criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Residents present: 16
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the renewal inspection |
| Staff 2 | Named in multiple findings related to training, certification, first aid, and criminal history record | |
| Staff 1 | Named in finding related to orientation completion | |
| Staff 3 | Named in finding related to annual training | |
| Staff 4 | Interviewed staff confirming multiple findings |
Inspection Report
Monitoring
Deficiencies: 1
Feb 17, 2022
Visit Reason
A focused non-mandated monitoring inspection was conducted on 02/17/2022 to follow-up on high risk violations cited during the facility's renewal inspection.
Findings
The facility failed to ensure that the medication administration record (MAR) included all required information for a resident's physician order. The pharmacy printed a new MAR with the correct MD order as a plan of correction.
Deficiencies (1)
| Description |
|---|
| The medication administration record (MAR) did not include all required information for resident 1's physician order regarding contacting the MD if bpm is <40. |
Report Facts
Date of physician's order: Dec 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the inspection |
| Nurse Manager | Spoke with licensing inspector and participated in exit interview |
Inspection Report
Renewal
Census: 13
Deficiencies: 17
Dec 15, 2021
Visit Reason
The inspection was an unannounced renewal study conducted to assess compliance with the Standards for Assisted Living Facilities, including a tour, medication observation, record reviews, and staff interviews.
Findings
The facility was found deficient in multiple areas including staff training, documentation of certifications, resident admission screenings, individualized service plans, medication administration, safety signage, hazardous materials storage, and required postings. Plans of correction were provided for each deficiency.
Deficiencies (17)
| Description |
|---|
| Failed to ensure all direct care staff attended six hours of training in working with individuals who have cognitive impairment within four months of employment. |
| Failed to obtain a copy of the certificate or documentation that staff met required standards before employment. |
| Failed to ensure all direct care staff attended at least 18 hours of annual training. |
| Failed to ensure each staff person submitted tuberculosis risk assessment results prior to or within seven days of employment. |
| Failed to ensure direct care staff received first aid certification within 60 days of employment if not already certified. |
| Failed to ascertain prior to admission whether a potential resident is a registered sex offender. |
| Failed to ensure all required information was included in resident agreements. |
| Failed to update resident individualized service plans to address all identified needs. |
| Failed to ensure the master individualized service plan was filed in resident records. |
| Failed to ensure a resident photo or current narrative description was in the record. |
| Failed to ensure physician orders were filed in resident records. |
| Failed to ensure all medications were administered in accordance with physician instructions. |
| Failed to post 'No Smoking-Oxygen in Use' signs when oxygen therapy is provided. |
| Failed to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Failed to post findings of the most recent inspection of the facility. |
| Failed to ensure sworn statement or affirmation was completed for all applicants for employment before hire. |
| Failed to ensure a criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Residents in care: 13
Staff training hours: 6
Staff training hours: 18
Timeframe for first aid certification: 60
Date of inspection: Dec 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Interviewed staff confirming multiple deficiencies and facility conditions | |
| Staff 2 | Staff record reviewed for training and certification deficiencies | |
| Staff 3 | Staff record reviewed for TB risk assessment, sworn statement, and criminal history report deficiencies | |
| Staff 4 | Staff record reviewed for training, certification, sworn statement, and criminal history report deficiencies | |
| Staff 5 | Staff record reviewed for sworn statement deficiency | |
| Nurse Manager | Participated in exit interview and discussion of findings |
Inspection Report
Renewal
Census: 12
Deficiencies: 6
Nov 19, 2020
Visit Reason
A renewal inspection was initiated on 11/19/2020 and concluded on 11/24/2020 to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple non-compliances including failure to ensure staff received required training on managing aggressive behavior, incomplete physical examinations prior to admission, lack of annual tuberculosis testing for residents, incomplete Uniform Assessment Instruments, inadequate Individualized Service Plans, and failure to conduct six-month medication reviews as required.
Deficiencies (6)
| Description |
|---|
| Failure to ensure staff training included demonstration in self-protection and prevention and de-escalation of aggressive behavior. |
| Failure to ensure physical examination was completed as required prior to resident admission. |
| Failure to ensure tuberculosis testing was completed annually for residents. |
| Failure to ensure the Uniform Assessment Instrument was completed as required. |
| Failure to ensure the Individualized Service Plan addressed all identified needs. |
| Failure to ensure a licensed health care professional performed medication reviews every six months for residents assessed for assisted living care. |
Report Facts
Staff census: 12
Staff hire date: Oct 14, 2017
Staff hire date: Sep 30, 2020
Resident admission date: Jul 2, 2018
Date of last TB test: Nov 30, 2018
Date of last medication review: Nov 19, 2019
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