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: Feb. 21, 2023 and Feb. 23, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

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: An unannounced renewal inspection took place on 02/21/2023 from 8:32 am to 5:20 pm and on 02/23/2023 from 9:04 am to 1:00 pm. 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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on the record review the facility failed to ensure in accordance with 63.2-1808 of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans. Evidence: 1. Resident #1?s medication administration record (MAR) for February 2023 documents the resident is prescribed, Lexapro. The record does not contain documentation of a treatment plan for the psychotropic medication, Lexapro. 2. Resident #2?s MAR for February 2023 documents the resident is prescribed Sertraline (Zoloft) for Major Depression. The record does not contain documentation of a treatment plan for the psychotropic medication, Sertraline (Zoloft). 22VAC40-73-320-B Based on the record review the
Plan of Correction:	1.Resident #1 and #2?s treatment plan was updated to include use of psychoactive medication. 2.All residents receiving psychotropic medications will be audited to ensure treatment plan is updated and accurate. 3.Director of AL/designee will educate staff on documentation of psychotropic medication on the treatment plan in the EMR. 4.Director of AL/designee will audit Four residents weekly for eight weeks to ensure those residents on psychotropic medications have accurate documentation on their treatment plan. Results of the audit will be reported at the QA
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidenced by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence: 1. The record for resident #5 contains a risk assessment for TB dated 03/02/2020. There is no documentation in the record of a risk assessment for TB completed after 03/02/2020.
Plan of Correction:	1.Resident #5 TB risk assessment was updated on 3/7/2023 by the licensed nurse. 2.All residents TB risk assessment will be audited to ensure it is updated and accurate. 3.Director of AL/designee will educate staff on updating TB screens annually and the proper documentation in the EMR. 4.Director of AL/designee will audit four residents weekly for eight weeks to ensure TB screens are up to date and accurate. Results of the audit will be reported at the QA meeting.
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record for resident # 1 did not include documentation of an orientation upon her admission date of 11/01/22.
Plan of Correction:	1.Resident #1?s acknowledgement of orientation was reviewed and signed by the resident on 3/8/2023 with the Director of Resident Services 2.All resident?s acknowledgement of receiving orientation will be audited to ensure it is signed and dated by the resident/legal guardian and the medical record. 3.Administrator will educate the Director of AL and Director of Resident Services on providing an orientation for all new resident?s and legal guardian and it shall be signed, dated, and kept in the medical record. 4.Administrator/designee will audit all new admissions weekly for eight weeks to ensure orientation to AL is reviewed, signed, and dated. Results of the audit will be reported at the QA meeting.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission at least annually, and whenever there is a significant change in the resident?s condition. Evidence: 1. The record for resident #1 documents an admission date of 11/01/22. The record contains a UAI dated 11/03/22, which was completed after the resident?s admission date. 2. The record for resident # 3 contains a UAI dated 04/26/21 and 01/27/23. There is no documentation in the record of an UAI being completed annually after 04/26/21. 3. The record for resident #6 documents an admission date of 11/14/22. The record contains an UAI dated 11/15/22, which was completed after the resident?s admission date. 4. The record for resident #6 contains a hospice admission date of 12/23/22. There is no documentation in the record of an UAI being completed for the resident after the significant change in condition for hospice care.
Plan of Correction:	1.Residents #1 and #6 had their UAI?s reviewed for accuracy and appropriate level of care by the Director of AL. Resident #3?s annual UAI was completed by the Director of AL. Resident #6?s UAI was completed and updated for significant change in condition by the Director of AL. 2.All residents UAI?s will be audited to ensure completion prior to admission with appropriate level of care, annually and if a significant change in condition. 3.Administrator/designee will educate the Director of AL/designee on UAI process to ensure completion prior to admission at least annually, and whenever there is a significant change in resident?s condition. 4.Administrator/designee will audit four charts weekly for eight weeks to ensure UAI?s are completed prior to admission, annually and with any significant changes in condition. Results of the audit will be reported at the QA meeting.
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. The record for resident #1 does not contain a preliminary plan of care or an individualized service plan (ISP) completed on or prior to the resident?s admission date of 11/01/22.
Plan of Correction:	1.Resident #1 had their preliminary plan of care and ISP reviewed for accuracy by the Director of AL. 2.All residents preliminary plan of care and ISP will be reviewed to ensure on or within seven days prior to admission it was developed to address basic needs of resident and protects their health, safety, and welfare. 3.Administrator/designee will educate the Director of AL/designee on completion of preliminary plan of care or ISP is developed on or within seven days prior to admission to address the basic needs of the resident that adequately protects his health, safety, and welfare. 4.Administrator/designee will audit four charts weekly for eight weeks to ensure ISP was developed on or within seven days prior to the day of admission. Results of the audit will be reported at the QA meeting.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the ISP includes a description of identified needs based upon the UAI. Evidence: 1. Resident # 1?s UAI dated 11/03/22 documents help needed for housekeeping, laundry, and money management. The ISP dated 11/10/22 does not include documentation of the help to be provided for housekeeping, laundry, and money management. 2. Resident # 2?s UAI dated 01/25/23 documents help needed for housekeeping, laundry, and money management. The ISP dated 02/20/23 does not include documentation of the help to be provided for housekeeping, laundry, and money management. 3. Resident #5?s UAI dated 01/06/23 documents mechanical and human help needs for dressing. The ISP dated 01/06/23 does not include documentation of the mechanical and human help supports needed for dressing. 4.Resident #6?s UAI dated 11/15/22 documents mechanical help needs for bathing, toileting, transferring, and mobility. The ISP dated 11/16/22 does not include the documentation of the mechanical supports needed for bathing, toileting, transferring, and mobility.
Plan of Correction:	1.Resident #1 and #2 ISP was updated the Director of AL/designee to provide help for housekeeping, laundry, and money management. Resident #5 ISP was updated the Director of AL/designee to include documentation of the mechanical and human help supports need for dressing. Resident #6 IPS was updated by the Director of AL/designee to include documentation of the mechanical supports needed for bathing, toileting, transferring and mobility. 2.All resident?s ISP?s will be audited to ensure that a description of identified needs are addressed based upon the UAI. 3.Administrator/designee will educate the Director of AL/designee on ensuring ISPs includes a description of identified needs based upon the UAI. 4.Administrator/designee will audit four charts weekly for eight weeks to ensure the ISP includes a description of identified needs based upon the UAI. The results of the audit will be reported to the QA meeting.
Standard #:	22VAC40-73-450-D
Description:	Based on the record review the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The Services provided by each shall be included on the individualized service plan. Evidence: 1. Resident?s # 6 ISP dated 11/16/22 does not include an update to include services provided for hospice care. The record documents a hospice admission date of 12/23/22.
Plan of Correction:	1.Resident #6 ISP was updated by the Director of AL/designee to reflect hospice care being on 12/23/2023. 2.All residents on hospice services will have the ISP reviewed to ensure an agreed upon plan of care and that the services provided are included in the ISP. 3.Administrator/designee will educate the Director Of AL on ensuring when hospice care is provided an Agreed upon coordinated POC and services provided is included on the ISP. 4.Administrator/designee will audit four hospice charts weekly for eight weeks to ensure a coordinated POC had been established and the services which are provided by each is on the ISP. The results of the audit will be reported to the QA meeting.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the ISP shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. Resident #1?s ISP signed and dated by the resident on 12/12/22 was not signed by the licensee staff. 2. Resident # 2?s ISP dated 02/20/23 was not signed by the licensee staff, and the resident or legal guardian.
Plan of Correction:	1.Resident #1 ISP on 12/12/22 was reviewed and signed by the licensed staff on 3/13/2023.Resident # 2 ISP on 2/20/23 was reviewed with the resident and/or legal guardian and signed by licensed staff and resident?s legal guardian on 3/13/2023. 2.All ISP?s will be reviewed to ensure they are signed and dated by licensed staff/designee and resident or legal guardian. 3. Administrator/designee will educate Director of AL/designee on ensuring the ISP is signed and dated by the licensed staff/designee, and by the resident or legal guardian. 4.Administrator/designee will audit four ISP?s weekly for eight weeks to ensure the ISP is signed and dated by the licensed staff/designee and by the resident or legal guardian. The results of the audit will be reviewed at the QA meeting.
Standard #:	22VAC40-73-450-F
Description:	Based on the record review the facility failed to ensure the ISP shall be reviewed and updated at least once every 12 months. Evidence 1.The record for resident # 3 contains an ISP dated 04/26/21 and 01/27/23. There is no documentation in the record of an ISP being completed 12 months after 04/26/21.
Plan of Correction:	1.Resident #3 ISP was reviewed and updated on 3/13/23 By the Director of AL for annual review. 2.All ISP?s will be audited to ensure they have been updated at least once every 12 months. 3.Administrator/designee will educate the Director of AL on ensuring the ISP is reviewed and updated at least once every 12 months. 4.Administrator/designee will audit four ISP?s weekly for eight weeks to ensure it has been reviewed and updated at least every 12 months. The results of the audit will be reviewed at the QA meeting.
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. During observation with staff #1 the following expired medications were observed on the medication cart: Rosuvastatin 10 mg expired 01/21/23 for resident # 10; Atorvastatin 80 mg expired 12/28/22 for resident #11.
Plan of Correction:	1.Staff #1 was provided 1:1 education by the Director of AL/designee regarding medication management to prevent use of outdated medications. Residents #10 and #11 did not sustain adverse outcomes from expired medication. 2. All medication carts will be audited to ensure no medications are outdated. 3.Director of AL/designee will educate staff on medication management to include methods to prevent the use of outdated medications. 4.Director of AL/designee will audit two medication carts weekly for eight weeks to ensure all medications have not expired. The results of the audit will be reviewed at the QA meeting.
Standard #:	22VAC40-73-680-G
Description:	Based on observation the facility failed to ensure over-the counter medication shall remain in the original counter and labeled with the resident?s name. Evidence: 1. During observation of the medication cart with staff # 2 the following medications were not labeled with a resident?s name: Colon Health Daily Probiotic, Claritin, Preservision, Tylenol, Saw Palmetto, Narcan Nasal Spray, Centrum Silver, Vitamins.
Plan of Correction:	1.Staff # 2 was provided 1:1 education by the Director of AL/designee regarding medication bottles no labeled with the resident?s name. 2.All medication carts will be audited to ensure all medication bottles have a label with the resident?s name. 3.Director of AL/designee will educate the staff on ensuring over-the-counter medications shall remain in the original container and labeled with the resident?s name. 4.Director of AL/designee will audit two med carts weekly for eight weeks to ensure over-the-counter medications are in the original container and labeled with the resident?s name. The results of the audits will be reported at the QA meeting.