VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Indian River Assisted Living
1012 Justis Street
Chesapeake, VA 23325
(757) 523-4659

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Oct. 13, 2020 , Oct. 14, 2020 , Oct. 15, 2020 and Oct. 16, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on October 13, 2020 and concluded on October 16, 2020. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services, Personnel, and Resident Accommodations and Related Provisions. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. Consultation provided in areas of telephone use by residents and staff training regarding population in care. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure the licensee ensured compliance with the facility's own policies, that residents are free from mental or emotional abuse. Evidence: 1. The facility?s ?Progressive Discipline Documentation? documented the following incidents: A. Staff #2 received counseling on 09-16-2020 regarding resident #1. ?Coaching Counseling with [staff #2] documented, ??[resident #1] approached me in tears telling me that [staff #2] ruined her morning by barging in and scolding her without a ?good morning? or pleasant greeting. The resident was in tears complaining how rudely she is treated the majority of the time by [staff #2].? B. Staff #4 was terminated on 09-24-2020 with documentation of the following incident dated 09-16-2020, ?? [staff #4] was behind [resident #1] when she heard [staff #4] call [resident #1] ?white trash?. Another incident on the document dated 09-21-2020 documented, ?? another anonymous complaint came in on [staff #4] cursing another resident, [resident #4] on Saturday, September 5?? C. Staff #3 received counseling on 10-02-2020 that documented, ??One of the residents, [resident #5], who did not want to follow the posted scheduled smoke breaks went rogue and went outside on her own around 7ish pm to smoke. [Staff #3] was upset with this resident and to get the resident?s attention, locked the front doors.? For approximately 10 minutes according to interviews. 2. Staff #1 acknowledged the aforementioned staff did not comply with facility?s own policy that residents are free from mental or emotional abuse.
Plan of Correction:	1. One on one counseling and training about Resident?s Rights with the referenced employees. We will continue to coach and counsel employees and use the established disciplinary process up to and including termination for violations of Resident?s Rights. Completed immediately 10/20/20 and on-going. 2. Conduct a series of employee in-services on mental health, dementia, communication, re-direction of behaviors, and meaningful activities. Joan Motley, CDP ? Interim on 10/21/20. Renaissance Counseling on 11/4/20. Teepa Snow self-paced videos to be completed by 11/30/20. 3. All staff will be immediately enrolled in online modules for Resident Rights and Bullying. To be completed by 11/30/20.
Standard #:	22VAC40-73-230-B
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure there was a written agreement between the facility and any resident who performs staff duties, to include specific duties, hours of work, and compensation. Evidence: 1. Resident #3?s Individualized Service Plan (ISP) dated 12-06-19 documented ?Resident request to engage in typical work type activity 10/11/2019. Community will provide work type activities constructed of residents needs made at a volunteer base for resident.? 2. There was no written agreement provided by the facility to document resident?s specific duties, hours of work, and compensation. 3. Staff #1 and staff #6 confirmed resident #3 likes to assist with duties; however, no written agreement was provided during inspection.
Plan of Correction:	1. All residents who perform work-type activities will have a volunteer agreement on file. 10/20/20 2. All volunteer type activities were ceased until agreements were signed by all required parties. Completed 10/20/20
Standard #:	22VAC40-73-590-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure snacks were made available at all times for all residents. Evidence: 1. The facility?s Disclosure statement documented, ?Snack service ? available 24 hours per day?. 2. Resident Council notes dated 09-03-2020 documented, ?Snack and ice times remain the same at 10am and 2pm and the dietary aide will bring to the rooms.? Additionally, Resident Council Meeting notes dated 10-08-2020 documented, ?Snack and ice times are still the same at 10am and 2pm. For the ice the Residents will have to go to the dining room and the snacks will be deliver to the rooms.? 3. Interviews with four residents confirmed that snacks are distributed at certain times of the day and not outside of the allotted time window. 4. Staff #1 acknowledged the statements that were reported by residents, as well as documentation in Resident Council notes regarding snacks.
Plan of Correction:	1. Snacks will remain available at all times. To be completed 10/20/20 and on-going. 2. An additional night time snack pass will be added after dinner so residents are more aware that snacks are available throughout the night. Between when staff pass snacks they will be available at the nurses station by request. Started 10/21/20 3. We will place a poster at the nurses? station informing all residents and staff that snacks are always available upon request. To be completed by 11/30/20.