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: July 1, 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 07/01/2024 from 10:10 am to 12:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (self-reported incident) was received by VDSS Division of Licensing on 06/03/2024 regarding allegations in the area(s) of: Resident Care and Related Services and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the facility?s Safe Secure environment to include resident rooms, doors, and windows were completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the (self-report) 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 #:	22VAC40-73-450-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. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #1, admission date of 03/21/24 does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. 2. The record for resident #1, contains an ISP dated as completed and initiated on 03/22/24, which is after the resident?s admission and move in date of 03/21/24.
Plan of Correction:	1.Resident #1 preliminary plan of care/ ISP was completed by the AL Director on 3/22/24. 2.All residents admitted to the memory care unit, will have preliminary plan of care/ISP?s audited to ensure completion prior to their admission date. 3.Administrator/designee will provide education to AL Director, Marketing Director and nursing on regulation that preliminary plan of care/ISP?s must be completed at least seven days prior to admission. 4.Will audit all new admission charts for 3 months to ensure that the preliminary plan of care/ISP has been completed prior to admission. Results of the audit will be reviewed at the monthly COR/QA meeting for trends. 5.All corrective action will be completed by 8/30/2024.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the UAI (Uniform Assessment Instrument). Evidence: 1. Resident?s #1 UAI dated 03/21/24 includes the following: a behavior pattern of wandering and states ?Wanders at time;? ?Disoriented to time and place.? Resident?s #1 ISP dated 03/22/24 does not include a need to address the resident?s behavior pattern of wandering and disorientation to time and place.
Plan of Correction:	1.Resident #1 UAI dated 3/21/24 and ISP dated 3/22/24 was updated by the AL Director to include residents behavior pattern of wandering and disorientation to time and place on 5/30/24. 2.All residents who have a behavior of wandering and are disoriented to time and place, their UAI and ISP will be accessed to ensure the needs are addressed. 3.Assisted Living Director/designee will provide education to the clinical team on ensuring that the UAI and ISP include behavior patterns and orientation. 4.Will audit 3 charts for 8 weeks to ensure that the residents UAI and ISP addresses residents? behavior patterns and orientation. Results of the audit will be reviewed at the monthly COR/QA meeting for trends. 5.All corrective action will be completed by 8/30/2024.
Standard #:	22VAC40-73-460-D
Description:	Based on the staff interview and the record review the facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. Resident?s #1 ?incident report? dated 05/30/24 documents the following: ?at approximately 3pm on 5/30/24, Isle of Wight police arrived at the facility with resident #1;? ?resident was picked up on main road that runs in front of the facility and returned to us;? ?resident #1 opened his window and removed the screen and climbed out.? 2. Staff #1 confirmed on 5/30/24 resident #1 exited the safe, secure environment through the window located in the resident?s room, and the police located the resident on a road located off the premises of the facility. 3. Staff #1 confirmed the staff on duty was not aware resident #1 exited the facility on 05/30/24 until the police returned the resident to the facility. 4. The record for resident #1 contains the following: An approval for placement in the safe secure environment dated 03/18/24. An UAI dated 03/21/24 that documents a behavior of wandering and disorientation to time and place; A physical exam dated 03/21/24 that documents a diagnosis of dementia.
Plan of Correction:	1.Resident #1 was returned to the facility on 5/30/24 by the local police and was assessed by the AL Director for any injuries and none were noted. Room was assessed for safety and windows were secured on 5/30/24 but the facilities director to prevent further elopement. 2.All windows in resident rooms were checked by the facilities director on 5/30/24 and no variances were identified. 3.Administrator will educate the facilities director that he ensure residents being admitted to the memory care unit have had the windows checked and they lock with the appropriate locking mechanisms. 4.Will audit resident #1 room/weekly for 8 weeks to ensure that the locking mechanisms are working appropriately. Results of the audit will be reviewed at the monthly COR/QA meeting for trends. 5. All corrective action will be completed by 8/30/2024.
Standard #:	22VAC40-73-930-D
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: The facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained for two years. Evidence: 1. Resident?s #1 ISP dated 05/30/24 documents ?resident #1 wanders and will need every 1 hour visual check.? The facility did not have documentation of the completion of one hour rounding to include every 1 hour visual checks for resident #1.
Plan of Correction:	1.Resident #1 was returned to the facility on 5/30/24. Rounds are being made on the resident hourly and documented. 2.All residents that have exit seeking behaviors will be rounded on every hour and documented. 3.AL Director will educate the clinical team on rounding on residents with exit seeking behaviors every hour and documenting it in the EMR. 4.AL Director will audit 3 residents for 8 weeks to ensure that documentation is present and accurate for exit seeking residents. Results of the audit will be reviewed at the monthly COR/QA meeting for trends. 5.All corrective actions will be completed by 8/30/24.