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: April 3, 2023

Complaint Related: Yes

Areas Reviewed:

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 04/03/2023 at 9:26am until 1:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (03/28/2023) regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The following were reviewed emergency preparedness procedures, secured exit doors was checked, and the door alarm system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (self-report) but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-1040-A
Complaint related:	No
Description:	Based on the record review and staff interview the facility failed to ensure doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence: 1.During an interview with staff #2, the staff confirmed the following: resident #3 exited a door leading to the outside of the facility; the door alarm was not ?ON? and did not make a sound when the resident exited the door on 03/05/2023. 2.The record for resident # 3 contains medical and psychological notes dated 01/20/23, 01/20/23, 01/26/23, 01/30/23 that documents the resident is disoriented to place, has a diagnosis of a cognitive impairment, and a diagnosis of cerebrovascular disease to include suspect vascular dementia w/ noted ischemia.? The resident?s record contains a physician order dated 01/25/23 for ?Namenda Titrate, give 5mg orally one time a day for Dementia w/ behavioral sx.? 3.The record for resident #3 contains a physician note dated 03/05/23 that documents ?at approx.3 am resident was noted not to be in his room. He was found outside in the back parking lot of the facility laying on the ground on his right side.? The resident was transferred to the ER.
Plan of Correction:	1) The egress door was immediately checked for proper functioning by the Director of Facilities on 3/6/2023. The alarm was immediately reactivated. Labels applied to the alarm panel with green and red labeling to indicate the functionality of the egress doors. Resident #3 no longer resides in the facility. 2) All doors were checked by Director of Facilities on 3/6/2023 on the unit to ensure they are functioning properly. 3) Administrator educated team members on ensuring egress doors have functioning security monitors and are working properly. 4) Egress doors in Assisted Living will be checked by the Director of Facilities/Designee for 2 times a week for 4 weeks to ensure functioning security monitors are working properly. Results of audit will be reported at QA meeting. 5) All corrective action will be completed by 5/19/2023
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on the record review and staff interview the facility did not report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1.The record for resident # 3 contains a progress note dated 03/05/2023 that documents ?at approx..3 am resident was noted to not be in his room. Resident was found outside in the back parking lot of the facility laying on the ground, complaining of right shoulder and right pelvic pain.? The resident was transferred to the hospital ER via 911.The record contains a hospital admission date of 03/05/2023. 2.Staff #2 acknowledged the facility did not report to the regional licensing office within 24 hours a report of the resident being found laying on the ground, transferred to the ER, and a hospital admission that occurred on 03/05/2023. The incident report was provided to the inspector during the on-site inspection completed on 04/03/2023.
Plan of Correction:	1) Resident #3 no longer resides in the facility as of 3/5/23. 2) All events/incidents that occur in Assisted Living will be reviewed by Administrator to determine if they are reportable. 3) Administrator/Designee will educate team members on the reporting requirements for Assisted Living to include event type and timeliness. Educator completed education with assisted living staff on resident elopement, prevention of elopement, and elopement risk assessment on 3/6/23 and 4/3/23. 4) Administrator/Designee will review risk management system weekly x 4 weeks to ensure all reportable events have been reportable timely. Results of audit will be reported at the QA meeting. 5) All corrective action will be completed by 5/19/2023.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the uniform assessment instrument (UAI) shall be completed whenever there is a significant change in the resident?s condition. Evidence: 1.The record for resident #3 contains a psychological note dated 01/20/2023 and a medical note dated 01/23/23 that documents the resident is ?disoriented? to place. The record contains a behavior note dated 02/03/23 that documents ?resident had to be redirected to time, place, and situation several times throughout the shift.? The UAI in the record dated 12/14/22 documents the resident?s orientation as ?oriented.? The record does not contain an UAI that documents the resident?s orientation as disoriented.
Plan of Correction:	1) Resident #3 no longer resides in the facility as of 3/5/23. 2) All residents who receive psychology services will have recent note reviewed and have their UAI updated related to any documented in change in orientation as noted. 3) Director/Designee will educate assisted living team on reviewing psychology provider documentation and updating UAI per changes in resident condition. 4) Director/Designee will audit 2 resident charts for 4 weeks to ensure documentation in provider notes are reflected on the UAI. Results of audit will be reported at QA meeting. 5) All corrective action will be completed by 5/19/2023.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated as needed for a significant change of a resident?s condition. Evidence: 1.The record for resident #3 contains a psychological note dated 01/20/2023 and a medical note dated 01/23/23 that documents the resident is ?disoriented? to place. The record contains a behavior note dated 02/03/23 that documents ?resident had to be redirected to time, place, and situation several times throughout the shift.? The ISP in the record is dated 12/14/22. The record does not contain an ISP that documents the resident?s orientation as disoriented. 2.The record for resident # 3 contains a psychological note dated 01/20/23 and 01/26/23 that documents a diagnosis of a ?cognitive impairment.? The resident?s record contains a medical note dated 01/20/23 that documents a diagnosis of ?Cerebrovascular disease to include suspect vascular dementia w/ noted ischemia.? The resident?s record contains a physician order dated 01/25/23 for administration of ?Namenda Titrate, give 5mg orally one time a day for Dementia w/ behavioral sx.? The resident?s record contains a medical note dated 01/30/23 that documents a chief complaint of ?dementia with behavioral sx.? The resident?s record contains an ISP dated 12/14/22. The resident?s record does not contain an ISP that documents a diagnosis and treatment for dementia or a cognitive impairment.
Plan of Correction:	1) Resident #3 no longer resides in the facility as of 3/5/23. 2) All residents who have a diagnosis of dementia or change in orientation, will have their ISP reviewed to ensure the diagnosis is included and treatment are included on the ISP. 3) Director/Designee will educate the team in reviewing provider documentation related to dementia and update the ISP related to changes in resident condition. 4) Director/Designee will audit 2 resident charts for 4 weeks to ensure documentation in provider notes are reflected on the UAL Results of audit will be reported at QA meeting. 5) All corrective action will be completed by 5/19/2023.