VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Riverside Assisted Living at Smithfield
101 John Rolfe Drive
Smithfield, VA 23430
(757) 357-3282

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 20, 2020 and May 21, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

This inspection was conducted by licensing staff using an alternative remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was conducted on May 20, 2020 and concluded on May 21, 2020. The administrator was contacted by telephone to conduct the inspection. The licensing inspectors emailed the administrator a list of documentation required to complete the renewal inspection. The licensing representatives reviewed staff schedule for the past 2 weeks, most recent Health Care Oversight, most recent Fire Inspection Report, most recent Health Department Inspection Report, Fire and Emergency drills for the past 3 months, resident records, and staff records. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on record review and discussion, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed at least annually, and whenever there is a significant change in the resident?s condition. Evidence: 1. Resident #2's current UAI was dated 10-22-18. Staff #1 could not provide documentation of resident #2's completed annual UAI. 2. Resident #1's Individualized Service Plan (ISP) dated 8-17-19 documented the resident requires mechanical and physical assistance for bathing with the use a grab bar and physical assistance for dressing; however, resident #1's UAI dated 8-08-19 documented the resident needs physical assistance for bathing and supervision for dressing and was not updated to reflect the resident's needs per the ISP. 3. Staff #1 confirmed resident #2?s UAI was not updated annually, and confirmed resident #1?s ISP was correct and the UAI was incorrect regarding bathing and dressing assistance needed.
Plan of Correction:	1. The UAI for resident #2 was a closed record and could not be updated. The UAI for resident #1 was corrected on 5/21/2020. 2. The Nurse Mentor/Designee will compete a 100% review and update of all residents? UAIs and ISPs by 7/17/2020. 3. The Resident Services Director/Designee will complete a second check of the UAI and ISP to ensure matching for all new admits, annual updates and significant changes. 4. Administrator/Designee will audit four (4) resident records to ensure UAIs and ISPs match and are individualized weekly for four (4) weeks, then monthly for three (3) months. Any variances will be addressed and reported to the QAPI Committee for continued analysis and improvement. Corrective action will be completed by 7/17/2020.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and discussion, the facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. The following residents? physician or other prescribed orders did not identify the diagnosis, condition, or specific indications for administering each drug: a. Resident #1?s physician?s orders dated 12-24-19 for Acetaminophen 325mg; b. Resident #2?s physician?s orders dated 3-10-20 for Aspirin Chew 81mg, Acetaminophen 325mg, Calcium Carbonate Chew 500mg, Ipratropium/Albuterol, Levetiracetam 750mg, Midrodrin 2.5mg, and Omeprazole 40mg; and c. Resident #3?s physician?s orders dated 5-6-2020 for Amlodipine 10mg, Clonazepam 0.5 mg, Glucosamine, Memantine 10mg, Sertraline 100mg, and Quetiapine 25mg. 2. Staff #1 acknowledged the residents? aforementioned physician orders did not identify the diagnoses, conditions, or specific indications for the aforementioned drugs.
Plan of Correction:	1. The diagnoses, conditions, or specific indications were added to the physician orders for resident numbers 1, 2 and 3 by 5/22/2020. 2. The Nurse Mentor/Designee will complete a 100% review and update of physician orders and medication administration records by 7/17/2020. 3. Nurses will be educated on the requirement of a diagnoses being associated with all medications and supplements by 6/26/2020. 4. Nurse Mentor/Designee will audit four (4) resident records to ensure diagnoses, conditions, or specific conditions are associated with all medications and supplements on physician orders and medication administration records weekly for four (4) weeks, then monthly ongoing. Any variances will be addressed and reported to the QAPI Committee for continued analysis and improvement. 5. Corrective action will be completed by 7/17/2020.