VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Riverside Assisted Living at Patriots Colony
6200 Patriots Colony Drive
Williamsburg, VA 23188
(757) 220-9000

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: March 22, 2019

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced renewal study was conducted by at Assisted Living at Patriots Colony on 3/22/19 (between the hours of 10:10a.m.- 3:45 p.m.) Licensing inspector was accompanied by another inspector from the Eastern Regional Office. The purpose of a renewal team inspection is to conduct an unannounced review of this facility with a primary focus on the above standards. There were 67 residents in care. Observations, reviews of the facility's records and interviews with staff (Flu Outbreak, did not interview resident) were conducted during this inspection visit. Violations cited were discussed with the administrator and the director of nursing.

Violations:

Standard #:	22VAC40-73-410-A
Description:	Based on record review and interview as sell as four of ten records, the facility failed to ensure the acknowledgement of having received orientation, and that 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. During Licensing Inspectors (LIs) record review, it was discovered that Residents #2, #3 and #4 did not have signed orientation acknowledgement documents in their files. 2. LIs confirmed with Staff #1 that orientation acknowledgements were not completed on Residents #2, #3, and #4.
Plan of Correction:	1. The activities coordinator will go over the resident orientation sheet with resident #2, #3, and #4. The residents or their representation will acknowledgement this information was given by signing and date the resident orientation sheet. 2. The Assisted Living Director reviewed all resident's charts to ensure a copy of the resident orientation sheet was signed and dated. Results of the audit will be reported to the QA Committee for continued improvements and analysis. 3. Upon admission, residents and their representative will review the resident orientation sheet with the activities coordinator/designee. 4. The assisted living director/designee will review two admissions weekly for four weeks to ensure the orientation acknowledgement has been signed and filed in the resident's record. Results of the audit will be reported to the QA Committee for continued improvements and analysis.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to ensure that the Uniformed Assessment Instrument was completed whenever there is a significant change in the resident's condition. Evidence: 1. During LIs record review, it was observed that Resident #2 is indicated to have appropriate behavior, but Staff #1 on census list listed resident as "aggressive". Resident #2 is reported to have aggressive behaviors on nursing notes observed by LI and confirmed by Staff #1. (The incidents occurred in January 2019 and March 2019) 2. Staff #1 confirmed that UAi had not been updated to reflect the behavior.
Plan of Correction:	1. The clinical team conducted a new Uniform Assessment Instrument to reflect resident #2's significant change due to having aggressive behavior on 4/15/2019. 2. A 100% audit of residents who have exhibited aggressive behavior in the last 30 days was conducted by the assisted living director to ensure a UAI was completed when appropriate. Results of the audit will be reported to the QA Committee for continued improvement and analysis. 3. Staff will be educated by the Assisted Living Director/designee on completing UAIs when a change in behavior is noted.
Standard #:	22VAC40-73-450-E
Description:	Based on record review and interview, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee (i.e. the person who has developed the plan), and by the resident or his legal representative. Individualized service plans shall be reviewed, updated once every 12 months, and as needed as the condition of the resident changes. Evidence: 1. LIs review of Resident #2's file revealed that the resident or their responsible party did not sign the ISP. 2. Resident #2's ISP did not show aggressive behavior listed despite Staff #1's confirmation that the Resident has aggressive behavior that were addressed in nursing notes reviewed by LI. 3. Nursing notes revealed on 01/24/2019 that nurses had spoken with Resident #2's son who stated that resident had called him expressing suicidal thoughts. Resident #2's ISP was dated 10/30/2018 and had not been updated to reflect resident's mental health status.
Plan of Correction:	1. Resident #2's ISP was updated on 4/15/2019 to their aggressive behavior and mental health status. Resident #2's ISP will be reviewed and signed by the resident or their representative. 2. The assisted living director reviewed all residents in springhouse to endure their ISP was signed by their representative. Results of the audit will be reported to the QA Committee for continued improvement and analysis. 3. On admission, annually and for significant changes, the resident, or legal representative will sign off on the ISP during the ISP meeting. The assisted living director will develop a tracking tool of when ISP's are due and ensure that staff are updating the ISP as needed. 4. The assisted living director/designee will review 3 charts each week for 4 weeks to ensure the ISP's are accurate and signed by the resident/ representative. Results of the audit will be reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-550-G
Description:	Based on record review and interview, three of ten resident records, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually. Evidence: 1. During LIs record review, it was observed that Resident #1 had one Resident Rights acknowledgement form, last signed 05/29/2016. 2. Residents #9 and #10 did not have a written acknowledgement on an annual resident rights review in their record. 3. During interview with Staff #1, it was confirmed that annual Resident Rights reviews had not been documented for the year of 2017, 2018 or 2019.
Plan of Correction:	1. The activities coordinator reviewed the resident's rights with resident #1, #9, and #10 and their representatives. 2. A 100% audit will be conducted by the assisted living director/ designee to ensure documentation of the annual review of resident rights is filed in the resident's record. 3. The activities coordinator/designee will review resident rights during activities and resident council meetings. The activities coordinator/ designee will keep a copy of the signed resident rights and the original will be filed in the resident's record. The facility will review 3 resident rights at each resident council meeting. Resident rights will be distributed annually to each resident/ representative based o the month they moved into the facility by the activity coordinators/designee. 4. The assisted living director/ designee will audit 4 resident records per week for 4 weeks to ensure annual residents rights have been completed and are filed in the record.
Standard #:	22VAC40-73-710-B
Description:	Based on record review, the facility failed to ensure that if a restraint is used, it must be imposed in accordance with a physician's written order that specifies the condition, circumstances, and duration under which the restraint is to be used. Evidence: 1. Upon review of resident list of special needs, it was documented that Resident #1 and Resident #2 have bed rails in place. LIs did not observe a bed rail order for either Resident #1 or Resident #2 in resident records. 2. Staff #1 could not produce documentation of orders for bed rails for Resident #1 or Resident #2. 3. There was no consent for bed rails by Resident #1 or Resident #2's responsible parties in the records.
Plan of Correction:	The assisted Living Director collected the appropriate documentation for resident #1 and resident #2, which were missing restraint orders and consent for bed rails on 3/22/2019. 2. A 100% audit of resident beds was conducted by the assisted living director to ensure any observed bed rails have been documented appropriately in the resident's record. Results of the audit will be reported to the QA Committee for continued improvements and analysis. 3. Upon admission and during ISP meeting, education will be reviewed with the residents/ representatives regarding the use of bedrails and notifying staff prior to installing. Staff will be re-educated by the Assisted Living Director / designee on restraints. 4. Observations of 4 apartments will be conducted weekly for four weeks by Assisted Living Director/ designee to ensure only authorized bedrails are in use. Results of the audit will be reported to the QA Committee for continued improvements and analysis.