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: March 5, 2024

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 03/05/2024 from 8:12 am to 4:55 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: 54 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: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and lunch was observed. A medication pass observation was completed for three 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. 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 #:	22VAC40-73-1090-A
Description:	Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #4 is listed on the facility?s record as residing in the safe, secure environment. The record for resident #4 contains an approval for placement in the safe, secure environment dated 06/12/23. The record for resident #4 did not contain an assessment for a serious cognitive impairment. 2. Staff #6 confirmed resident #4 resides in the facility?s safe, secure environment and the record for resident #4 did not contain an assessment for serious cognitive impairment.
Plan of Correction:	Resident #4 chart was updated on 3/6/24 by the AL Director to ensure approval for placement of safe secure placement form and the assessment for serious cognitive impairment. Will audit residents charts in memory care to ensure that they all have the appropriate placement form and serious cognitive impairment forms are in place. Al Director designee will educate Marketing Director on approval from provider to ensure these forms are completed prior to admission and included with admission packet. audit 2 residents on the memory care unit weekly for 6 weeks to ensure record contains assessment for serious cognitive impairment to reside in the memory care unit. Audit results will be given to AL Director and Administrator to review and with the QAPI meeting.
Standard #:	22VAC40-73-320-A
Description:	Based on the onsite record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician and shall contain all included in this subsection. Evidence: 1. The record for resident #1, admission date 02/16/24, contains a physical exam that documents 01/04/24 as the date of the exam. The physical exam is dated as completed more than 30 days preceding the resident?s admission. 2. Resident?s #4 physical examination dated 05/11/23 did not include the following: Results of a risk assessment documenting the absence of tuberculosis (TB); A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H; A statement that specifies whether the individual is considered to be ambulatory or nonambulatory; A statement that specifies whether the individual is or is not capable of self-administering medication.
Plan of Correction:	Resident #1 has a current physical documented by the provider on 3/27/24. Resident #4 has had a current TB test on 3/6/24. Resident #4 is ambulatory and is not capable of self- administering medications. Residents admitted since 3/19/24 will have admission paperwork audited to ensure physical examination is within 30 days, TB risk assessment, ambulatory/non ambulatory and ability to self-administer and other requirements are completed timely. Administrator/designee will provide 1:1 education to the Admissions Coordinator/Marketing Director on regulations requirements/timeframes physical exam within 30 days, TB risk assessment, ambulatory/non ambulatory and if able to self- administer medication. Will audit residents residing in Assisted Living to ensure risk assessment for TB is updated along with conditions or care needs prohibited is up to date physical exam within 30 days of admission, TB risk assessment, ambulatory/non- ambulatory and ability to self- administer medication. Audit results will be given to the AL Director to review and results will be presented at the QAPI meeting.
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 03/02/2022. Resident?s #5 record does not contain documentation of a risk assessment for TB completed annually after 03/02/22. Resident #5 was discharged from the facility on 07/20/23.
Plan of Correction:	Resident #5's was discharged on the facility on 1116124. Will audit residents on admission to ensure they have TB assessment and date and set in Point Click care. Educator designee will provide education to the staff on requirement of completion of TB assessment upon admission and yearly. Will audit 2 resident's charts weekly for 6 weeks to ensure that TB risk assessments are completed and accurate. Audit results will be given to AL Director and Administrator to review and results will be presented at QAPI.
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 #3 contains an UAI dated 02/15/23. Resident?s # 3 record did not contain an annual UAI completed after 02/15/23. Staff #6 confirmed resident?s #3 record did not contain an annual UAI completed after 02/15/23. 2. Resident?s # 4 UAI is dated 05/31/23. The record for resident #4 contains a hospice care plan to include a hospice care effective date of 12/22/23. Resident?s #4 record did not contain a UAI completed when there was a significant change in the resident?s condition to include hospice care.
Plan of Correction:	Resident #3 annual UAI has been updated on 3/26/24 by AL Director. Resident # 4's UAI has been updated to include hospice care effective 011 12/22/23 and change in condition on 3/18/24 by AL Director. Will review the UAI report in Point Click Care to review who is due for UAl updates to ensure done timely. Will review residents on hospice to ensure it is completed on the UAL AL Director/designees will educate staff on reviewing PCC report for UAI updates to include hospice services. Will audit 3 resident charts weekly for 6 weeks for UAl's due dates as well as all residents on hospice to ensure they are up to date and all information included, Audit results will be given to AL Director and Administrator to review and results will be presented at QAPI.
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 the medication pass observation with staff #2, the following medication for resident # 7 was located on the medication cart and was expired: Hydralazine, expired 07/06/23.
Plan of Correction:	I. Resident #7's Hydralazine was removed from the cart and reordered on 3/5/24 by the AL Director. Med carts were all checked, and any expired meds were removed and reordered if necessary. Educator/designee will educate ieam ml!mbers to check all expiration dates on medications during medication pass. Will perform medication cart check weekly for 6 weeks to ensure medications have not expired. Audit results will be given to AL Director and Administrator to review and results will be presented at QAPT.
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 # 1 the following medication was not labeled with a resident?s name: Systane Lubricant eye drops
Plan of Correction:	Resident #1's Lubricant eye drops were removed from the medication cart and reordered on 3/5/24 by AL Director. The medication cart were checked for any non-labeled meds and were removed and reordered if necessary. Educator'/designee will educate team members to check for non-labeled med on medications carts during the medication pass. audit of med carts weekly for 6 weeks to ensure there are no unlabeled medications and if so will be discarded and reordered with resident information. Audit results will be given lo the AL director to review the result at the QAPl meeting.