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: May 21, 2021 , May 24, 2021 , May 27, 2021 and June 2, 2021

Complaint Related: No

Areas Reviewed:

Part III: PERSONNEL Part IV: STAFFING and SUPERVISION Part V: ADMISSION, RETENTION AN DISCHARGE OF RESIDENTS Part VI: RESIDENT CARE AND RELATED SERVICES Part IX: EMERGNECY PREPAREDNESS Part X: Additional Requirements for Facilities with SERIOUS COGNITIVE IMPAIRMENTS

Comments:

This inspection was conducted by the licensing staff using an alternate remote protocol necessary due to the state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5-21-21. The assisted living manager was contacted by telephone to initiate the inspection. The administrator reported that current census was 50. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three staff records, three resident records, healthcare oversight, nutrition report, staff schedules, sworn disclosure and criminal record report and fire and emergency drills also fire and health inspections. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based on record review and staff interview, the facility failed to ensure the uniformed assessment instrument (UAI) for one of three residents was completed as required. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) documented a reassessment date of 1-8-21 did not include the name, signature and date of the individual who completed the assessment and who reviewed the assessment. 2. A review of other UAIs submitted were completed as required. 3. On 5-27-21 and 6-2-21, staff #1 and #2 acknowledged the UAI was not complete as required.
Plan of Correction:	The signature on the UAI was corrected for resident #1on June,3rd,2021 Director/designee will do a 100% audit on UAI's/ISP's on reassessments. Director/designee will educate the staff trained to do UAI/ISP's on reassessments that updated signature is completed. Director/designee will audit 5 UAI's per week for 4 weeks that any reassessments have updated signatures and the findings will be reported at COR meeting for tracking and trending All corrective actions will be completed by July 17th,2021
Standard #:	22VAC40-73-650-A
Description:	Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #1?s nutrition report dated 2-26-21 documented resident received Boost as desired at least twice a day. On 5-27-21, staff #1, #2, and #5, acknowledged information documented in nutrition report regarding resident receiving Boost. 2. Staff #2 stated resident?s family supplied Boost for resident. Staff also stated resident received Boost intermittently. 3. On 5-27-21, the inspector requested from staff #1 and #2 the physician?s order for the Boost. 4. On 5-31-21, during the inspector?s interview with staff #6, staff stated resident did receive Boost. When asked if there was an order for the Boost, staff stated searching the resident?s record but was not able to locate a physician?s order for the Boost. 5. Staff #1 and #2 acknowledged during the final exit on 6-2-21, the facility did not have a physician?s order for Boost for resident #1.
Plan of Correction:	Resident #1 received an order for Boost twice daily as desired on June 3rd 2021. The responsible representative was notified of the order change. Director/designee will do a 100%audit on all residents receiving supplements that a provider order is in place. Director/designee will educate the clinical staff to cross check the monthly supplement report provided by the dietician to ensure that all orders are in place and the ISP's are updated. Director/designee will audit 5 residents on supplements weekly for 4 weeks to ensure that supplement orders and ISPs are current. The findings will be reported at COR meeting for tracking and trending. All corrective actions will be completed by July 17th, 2021