Riverside Assisted Living at Smithfield
Families consistently rate this highly — reviewers highlight excellent rehabilitation and therapy teams. Schedule a visit to confirm the fit.
based on 21 Google reviews
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What this means for your family
This facility is an excellent choice for short-term rehabilitation due to its highly rated therapy and nursing teams. However, families should closely monitor medication schedules and be prepared for potential delays in response times due to known staffing shortages.
Google Reviews
Google Reviews
21 reviews on Google“Families can expect a caring environment with highly praised rehabilitation and therapy services, particularly for short-term recovery. While many reviewers highlight the kindness of specific staff members and a clean facility, there are recurring mentions of staffing shortages and occasional delays in medication administration.”
Quality Themes
Tap a score for detailsStrengths
- Excellent rehabilitation and therapy teams
- Kind and professional nursing leadership
- Clean and well-maintained resident rooms
- Engaging activities and field trips
Concerns
- Staffing shortages affecting responsiveness (mentioned by 2 reviewers)
- Delays in medication administration (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 21 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1It's wonderful to see how much the leadership values feedback through your review responses; how does the management team use resident and family input to improve daily operations?
- 2We've heard great things about your therapy and rehab teams; could you tell us more about how they work with residents to maintain their mobility?
- 3What specific types of engaging activities or local field trips are currently popular with the residents here?
- 4Could you walk us through your process for medication administration to ensure everything is delivered accurately and on schedule?
- 5How does the nursing team manage resident care and responsiveness during shift changes or periods of high activity?
- 6What is the dining experience like here, and are there opportunities for residents to have input on the meal menus?
Personalized based on this facility's data
Key Review Excerpts
“After a bad experience with a local rehab facility my Mother was transferred to Riverside Lifelong Health and Rehabilitation Smithfield, and I have to say I couldn’t be more happy with that decision.”
“The therapy teams are amazing. She comes out bright, and stronger every time. It's a huge blessing to have a place like this we can trust, and count on.”
“Staff is friendly and kind! Martha is the heartbeat of this facility! She has a passion for the elderly and ensures that they are treated well.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Mar 19, 2026Routine
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 03/19/2026 at 8:35 am to 6:10 p.m. 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: 7 Number of staff records reviewed:3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, lunch, and an activity was observed. A medication pass observation was completed for three residents. The following were 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: 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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
Based on the record review and staff interview the facility failed to ensure based upon review of the UAI
Based on the record review and staff interview the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: 1. The record for resident #2, admission date 06/10/25, does not contain documentation of an acknowledgment that the resident or the legal representative received an orientation upon admission. 2. During an interview on 03/19/26 with staff #4, staff #4 confirmed the record for resident #2 did not contain documentation of an acknowledgment the resident received an orientation upon admission.
Based on the record review and staff interview the facility failed to ensure the Uniform Assessment Instrument ( UAI
Based on the record review and staff interview the facility failed to ensure on or within seven 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 is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #2, admission date 06/10/25, does not contain a preliminary plan of care completed on or within seven days prior to admission, nor a comprehensive individualized service plan ( ISP
Based on observation the facility failed to ensure all resident records shall be kept in a locked area. Evidence: 1. During a tour of the facility on 03/19/26 at 8:43 am the Licensing Inspector (LI) observed an opened, unlocked, and unstaffed office room (nurse?s station) that contained resident records. Photographic evidence is available.
Based on the observation of the water temperature, and staff interviews the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. During the onsite inspection on 03/19/26 the Licensing Inspector (LI) along with staff #5 measured the hot water, and the hot water reading was below 105?F in the following areas: ? 86.9?F in the bathroom of resident #8 ? 103.1?F in the bathroom of resident #9 ? 98.1 ?F in the common area bathroom used by residents.
Based on observation and staff interviews the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. During a tour of the facility on 03/19/26 at 10:19 am, the Licensing Inspector observed a signaling device located in the hallway hung from the ceiling which visibly alerted staff of a resident?s pull of the call bell and location of the resident?s room, however the signaling device was not audible. Video evidence is available. 2. During the Licensing Inspector observation of the nurse station on 03/19/25 at 8:43 am and 10:20 am the nurse?s station was not staffed. Photographic and video evidence is available. 3. During an interview on 03/19/26 with staff #1, staff #1 stated the signaling device in the hallways are not audible and the facility only has one audible signaling device that is located in the nurses station however the nurse?s station is not continuously staffed.
Mar 27, 2025Routine
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 03/27/2025 from 9:45 am to 1:50 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 03/13/2025 regarding allegations in the area of: The Safe Secure Environment 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: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: An observation of the facility?s exit doors and exit alarm signals located in the safe secure unit was 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
Based on the record review and staff interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment. Evidence: 1. Resident?s #1 final incident report dated 03/26/25 documents the following: On 03/13/25 staff # 4 was notified that ?resident #1 was missing around 10:17 am. Resident #1 was located less than 10 minutes later; resident #1 was found on the sofa right outside memory care door in assisted living. No staff or visitors had exited or entered the unit prior to the incident and when resident #1 wander guard was checked it was working upon return to the unit.? 2. During an interview on 03/27/25 with staff #1 and staff #2, both staff reported on the day of 03/13/25, staff #1 and staff #2 observed resident #1 around the time of 10:00am, however the staff did not observe resident #1 exit the safe secure unit. Staff #1 and staff #2 acknowledged not to hear a door alarm sound, and/or an alert from resident?s #1 wander guard when resident #1 exited the safe secure unit. 3. During an interview on 03/27/25 with staff #4, staff #4 explained that the exit doors located in the safe, secure unit are secured with a lock and the residents wander guards are to trigger an alert when a resident exits a secured exit door. Staff #4 acknowledged that when resident #1 exited the safe secure unit on 03/13/25 the safe secure unit exit doors alarm did not sound, and the resident?s wander guard did not trigger an alert to the facility staff.
Mar 27, 2025Routine
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 03/27/2025 from 9:45 am to 1:50 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 03/17/2025 regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: The facility staffing schedule was 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
Based on record review and staff interview the facility failed to ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked. Evidence: 1. Resident?s #1 incident reports dated 03/17/25 and 03/26/25 documents the following incident that occurred on the day of 03/13/25: Hospice nurse ?stated she found medication that was supposed to have been given sitting on bedside table;? ?the investigation noted that the resident?s lidocaine patch and lactulose liquid were at the bedside;? staff #1 did not remove or return to give the medicine to the resident. 2. During an interview on 03/27/25 with staff #1, staff #1 acknowledged on the day of 03/13/25, staff #1 did not remove the resident?s Lidocaine Patch and Lactulose Oral Solution from the bedside table when staff #1 exited from the resident?s room.
Based on the record review and staff interview the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #1 contains the following physician orders: A physician order dated 02/17/25, ?Lidocaine Patch 4%-left ribs apply 1 patch topically one time a day in the morning for pain remove in at bedtime.? A physician order dated 02/02/24 for ?Lactulose Oral Solution, Give 15ml by mouth two times a day for constipation, hold for stools.? 2. Resident?s #1 final incident report dated 03/26/25 documents the following for an incident that occurred on 03/13/25: ?the investigation noted that the resident?s lidocaine patch and lactulose liquid were at the bedside;? staff #1 stated that the resident did not want the medication and staff #1 did not remove or return to give the medicine to the resident. 3. Resident?s #1 March 2025 Medication Administration Record ( MAR
Feb 25, 2025Routine
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 02/25/2025 from 8:50 am to 4:40 pm and 02/27/2025 from 9:30 am to 12:42 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 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 and the water temperature was measured. The facility?s emergency water and food supply were observed. 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
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 the following: results of a risk assessment documenting the absence of tuberculosis; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H. Evidence: 1. The record for resident #3, admission date 04/04/23, does not contain a physical examination completed prior to admission. 2. The record for resident #3, admission date 04/04/23, does not contain results of a risk assessment completed prior to admission documenting the absence of tuberculosis. 2. Resident?s #6 physical examination does not include a statement to identify if the resident does or does not require continuous licensed nursing care.
Based on the record review the facility failed to ensure the Uniform Assessment Instrument ( UAI
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
Based on the record review the facility failed to ensure the individualized service plan ( ISP
Based on observation and the record review the facility failed to ensure medications shall be administered in accordance with the physician?s instructions. Evidence: 1. During the medication pass observation for resident #4, staff #2 administered the following crushed medications to resident #4: Magnesium, Metoprolol, Senna, Sertraline, Sodium, Vitamin B12, and Gabapentin. The record for resident #4 does not include a physician order with instructions to crush the resident?s medications.
Based on the onsite record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident?s attending physician; and that the written order is included in the individualized service plan ( ISP
Jul 1, 2024Routine
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
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
Based on the record review the facility failed to ensure the comprehensive individualized service plan ( ISP
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
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
Mar 5, 2024Routine
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
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.
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.
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.
Based on the record review the facility failed to ensure the Uniform Assessment Instrument ( UAI
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.
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
Mar 5, 2024Other
A (self-reported incident) was received by VDSS Division of Licensing on (02/18/2024) regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the facility?s exit doors and exit alarm signals was completed. An observation of the outside grounds and the road in which the facility is located was completed. A review of the facilities emergency drills 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
Based on the record review and staff interview the facility failed to ensure the facility shall 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 02/18/24 includes the following for the date of 02/16/24 at 11:30 pm: ?staff heard the alarm sound, immediately began doing room rounds, and noted resident was not in their room, resident was found outside with their wanderguard and project lifesaver bracelet on.? 2. Resident?s #1 progress note dated 02/16/24 documents the following: ?resident exited out of the building and was found up the road.? 3. Resident?s #1 record contains a description of event for 02/16/24 that documents the following: ?staff was assisting another resident with care. Staff noted south hall door alarm going off. Staff immediately started doing rounds. Resident was noted to not be in their room. Resident was found down the road walking with only a night gown on. Resident was noted to not be wearing any shoes or socks.? 3. During an interview with staff #1, staff #1 reported the following: On 02/16/24, staff #1 was in the car driving and saw resident #1 walking up the road, staff #1 located resident #1 at the stop sign (located on the street, Breanna Court) up the road from the facility, staff #1 assisted resident #1 with getting in the car and staff #1 drove resident #1 back to the facility. Staff #1 reported during the time of resident?s #1 elopement from facility, staff #2 was the only staff person working in the assisted living facility section of the building. 4. Resident #1 was admitted to the assisted living section of the facility on 02/16/24. Resident?s #1 Individualized Service Plan ( ISP
Jul 21, 2023Routine
ype 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 monitoring inspection took place on 07/21/2023 from 8:56 am to 12:55 pm 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 07/10/2023 regarding allegations in the area of: Admission, Retention, and Discharge of Residents and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the safe, secure unit was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation?s area(s) of non-compliance with standard(s) or law were: Admission, Retention, and Discharge of Residents and Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint 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
Based on the record review and staff interview the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrators the following information as listed in the section. Evidence: 1. The record for resident #1, discharge statement dated 06/05/23 did not include a date the discharge statement was provided to the resident and the resident?s designated contact person. Staff #1 confirmed the discharge statement was not provided to the resident and the resident?s designated contact person. 2. The record for resident #2, discharge statement dated 06/22/23, included documentation the resident, legal representative, and designated contact person was provided the discharge statement on 06/22/23, however staff #1 confirmed the discharge statement was not provided `to the resident, legal representative, and designated contact person.
Based on the record interview and staff interview the facility failed to maintain the completed Uniform Assessment Instrument ( UAI
Based on the record review the facility failed to ensure the individualized service plan ( ISP
Based on the record review the facility failed to ensure the ISP
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