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: April 3, 2023 , April 4, 2023 and April 28, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Renewal Dates: On-site renewal inspection conducted on 4-3-23 (AR 08:30/dep 5:40 p.m) 4-4-23 (AR 09:38/dep 2:00 p.m). The facility census was 64. An exit meeting was conducted with the administrator and other facility representatives on both days. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757)439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility should obtain the written approval of one of the individuals noted in the order of priority. The obtained written approval shall be retained in the resident?s file. Evidence: 1. On 4-3-23, resident #1?s record did not have documentation of the resident, guardian or legal representative, relative or independent physician (order of priority) providing approval for the resident to be place in the facility?s safe, secure unit. 2. Staff #1 acknowledged the record did not have documentation of approval from the required order of priority individual.
Plan of Correction:	1. Resident #1?s documentation placement of residents with serious cognitive impairment was obtained and signed by the legal representative on 5/2/2023. 2. All residents in the memory care unit will be audited to ensure the initial document for a resident with serious cognitive impairment has been signed in by the legal representative for approval and filed. 3. Administrator/designee will educate the marketing/admission team that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility should obtain the written approval of one of the individuals noted in the order of priority. The obtained written approval shall be retained in the residents? file. 4. Administrator/designee will audit all new admissions monthly for 3 months to ensure the document for a resident with serious cognitive impairment has been signed by the legal representative for approval and filed. The results of the audit will be at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-1110-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that prior to admitting a resident within a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident?s file. Evidence: 1. On 4-3-23, resident #1?s record did not have documentation of the facility?s determination and justification for the decision to place a resident in the safe, secure environment from the licensee, administrator, or designee. 2. Staff #1 acknowledged the aforementioned resident?s record did not have the requirement from the facility to place resident in the safe, secure environment.
Plan of Correction:	1. Resident # 1?s facility determination and justification for the decision to place the resident in the safe, secure environment was signed by the licensed administrator on 5/2/2023. 2. All residents in the memory care unit will be audited to ensure the initial document by the facilities determination and justification for the placement of the resident in the secure unit was signed by the licensed administrator/designee. 3. Executive Director will educate the administrator/designee on ensure that prior to admitting a resident within a serious cognitive impairment due to a primary psychiatric diagnosis of dementia safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination shall be in writing and retained in the resident?s file. 4. Executive Director/designee will audit all resident monthly for 3 months to ensure the record has documentation of the facilities determination and justification for the decision to place a resident in the safe, secure environment from the licensee administrator/designee. The results of the audit will be at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s record included the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it within 30 days preceding admission. Evidence: 1. On 4-3-23, resident #1?s risk assessment was dated 1-12-23. The resident?s date of admission was documented as 12-6-22. 2. On 4-4-23, resident #3?s record did not include documentation of a risk assessment. Resident?s date of admission documented as 3-29-23. 3. Staff #1 acknowledged the aforementioned residents? record did not have admission risk assessments per the required admissions timeframe.
Plan of Correction:	1. Resident #1 and #3 TB risk assessment was updated by the LPN on 5/1/23. Resident #3 TB risk assessment was signed by the provider on 4/4/23. 2. All residents? records will be audited to ensure a TB risk assessment was completed within 30 days preceding the admission. 3. Administrator/designee will educate marketing/admission and nursing staff on requirement of the TB risk assessment to be completed with in 30 days preceding admission to the facility. 4. Administrator/designee will audit 2 residents monthly for 3 months to ensure appropriate TB risk assessments was completed prior to admission. The results of the audit will be reported at COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-350-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ascertain, prior to each resident?s admission, whether the resident is a registered sex offender. Evidence: 1. On 4-3-23, resident #9?s record did not contain a sex offender screening document. 2. Staff #1 acknowledged the aforementioned resident?s record did not have a sex offender screening.
Plan of Correction:	1. The facility requested and received a sex offender inquiry for resident #9 on 4/3/23. Resident #9 is not a registered sex offender. 2. All residents? records will be audited to ensure they contain a sex offender screening document. 3. Administrator/designee will educate marketing/admission and nursing staff on the requirement that all residents must have a sex offender screening document completed prior to admission. 4. Administrator/designee will audit 2 residents monthly for 3 months to assure each record contain a sex offender screening prior to admission. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to or at the time of admission to the assisted living facility, the required personal and social information for residents were obtained and kept current. Evidence: 1. On 4-3-23, resident #2?s personal and social information data form did not include the resident?s allergy, Amoxicillin and dust mite. The resident?s physical examination document dated 8-5-21 noted resident?s allergy. 2. On 4-3-23, staff #1 acknowledged the aforementioned resident?s record did not include updated and/or completed personal social data information.
Plan of Correction:	1. Resident #2?s social data sheet was updated by the LPN to include allergies of Amoxicillin and dust mites as of 4/6/23. 2. All resident records will be audited to ensure each residents have a social data sheet has all personal and social information is present to include allergies. 3. Administrator/designee will educate clinical staff on completion of social data sheet on admission to include allergies in the EMR and to update social data sheet as changes occur. 4. Administrator/designee will audit 5 residents? charts weekly for 8 weeks to ensure that the social data sheet has all the required personal and social data. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-390-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure at or prior to the time of admission, there was a written agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator. This document included all of the requirements of 22VAC40-73-390-A. Copies of the signed agreement/acknowledgement shall be retained in the resident?s record. Evidence: 1. On 4-4-23, resident #3?s record did not include a signed and dated copy of the resident agreement/acknowledgement document. Staff #1 contacted the marketing office staff who stated that a resident agreement should be signed/dated. Staff #1 also spoke with the individual who signed the admissions document, that individual stated a resident agreement was not provided. 2. The record included documentation of an admission (sex offender, disclosure, written assurance, physical examination, orientation, interview and resident rights, UAI and ISP). 3. Staff #1 acknowledged the aforementioned resident?s record did not include a signed resident agreement for an admission to the assisted living facility. The resident was noted as a transfer resident. The resident previously resided in the independent section of the campus.
Plan of Correction:	1. Resident #3 had a resident agreement/acknowledgement document signed on 5/5/2023 by marketing/admissions. 2. All residents? records will be audited to ensure each resident has an admission contract. 3. Administrator/designee will educate marketing/admissions on the requirement of completed resident agreement/acknowledgement documents signed prior to admission. 4. Administrator/designee will audit 2 residents monthly for 3 months to assure appropriate resident agreement/acknowledgement document is signed prior to admission. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives. Acknowledgement of having received the orientation shall be signed and dated by the resident and, as appropriate, the legal representative, and such documentation shall be kept in the resident?s record. Evidence: 1. On 4-3-23, residents #7 and #9?s record did not contain documentation of resident?s orientation. 2. Staff #1 acknowledged the aforementioned residents record did not have documentation of orientation to the facility.
Plan of Correction:	1. Resident #7 and #9 acknowledgement of orientation was reviewed and signed by the resident on 5/1/23 with marketing and admissions. 2. All residents? records will be audited to ensure the orientation for residents and legal representative is signed and in the medical record. 3. Administrator/designee will educate the marketing/admissions on the requirement of providing an orientation for all new residents and legal guardians and it shall be signed, dated, and kept in the medical record. 4. Administrator/designee will audit all new admissions monthly for 3 months to ensure orientation to Assisted Living is reviewed, signed, dated, and kept in the medical record. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for residents. Evidence: 1. On 4-3-23, resident #1?s ISP dated 12-6-22 did not document who would provide services, frequency and where for bathing assessed need of mechanical help/supervision, dressing assessed as human help/supervision, behavior patterns assessed weekly or more and orientation assessed as disoriented some spheres all of the time (spheres: time, place, situation). Stairclimbing assessed as mechanical/human help needed, mechanical item and goal or is not documented. The resident?s date of admission noted as 12-6-22. 2. On 4-4-23, resident #3?s uniform assessment instrument (UAI) dated 3-7-23 documented resident behavior as appropriate. The ISP dated 3-29-23 documented the resident has ?serious cognitive impairment?Resident is (an Elopement Risk/unable to exit with one command in an emergency). Falls need did not document when, where and who would provide services to prevent major injury from falls. Wheeling documented as no help needed/ the ISP documented wheeling not performed. Resident observed on 4-3-23 walking and able to use if wheelchair if needed to. Bathing assessed as mechanical help/supervision on the UAI, dated 3-7-23. The ISP documented resident requires mechanical and physical human help, no documentation of who when and where services will be provided. Mobility assessed as mechanical and physical human help. The ISP did not document who, when and where services to be provided and did not document what mechanical help was needed. Stairclimbing assessed as mechanical/human help-physical and disoriented some spheres some time (time), these needs are not addressed on the ISP. Resident?s date of admission noted as 3-29-23. 3. On 4-3-23 and 4-4-23, staff #1 acknowledged the aforementioned residents? ISP did not include all assessed needs.
Plan of Correction:	1. Resident #1?s ISP was updated on 5/1/23 to include who would provide services, frequency and where bathing would occur, and mechanical assistance needed for stairclimbing by the LPN. Resident #3?s ISP was updated on 5/1/23 to include who, when and where services are to be provided and document what mechanical help is needed. Stairclimbing was assessed and documented on the ISP by the LPN. 2. All residents? ISP will be audited to ensure the plan includes all assessed needs for each resident. 3. Administrator/designee will educate the clinical team on the requirements of the ISP to include all assessed needs for the resident. 4. Administrator/designee will audit 4 residents ISP?s weekly for 8 weeks to ensure the ISP includes all assessed needs for the residents. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, and observation made during the tour of the physical plant, the facility failed to document in the updated the individualized service plan (ISP)assessed needs and/or for significant change of resident?s condition. Evidence: 1. On 4-3-23, resident #2?s ISP dated 8-13-22, documented stairclimbing assessed as mechanical help/human supervision, the ISP did not document who, when or where services would be provided. Laundry services assessed as help need, who and when services were to be provided not documented. The resident?s date of admission noted as 8-3-21. 2. On 4-4-23, resident #10 had an identified need for physical therapy evaluation on 2-22-23 based on the facility?s fall risk screening. The facility obtained a verbal order for skilled physical therapy 2-3 times a week for 30 days on 3-16-23. The resident was not evaluated for physical therapy until 4-3-23 and physical therapy was not updated on the resident?s ISP until 4-4-23. The ISP did not contain a written description of the services to be provided to address the need and who will provide them, where the services will be provided, the expected outcome and the time frame for expected outcome. The resident?s ISP did not document what type of assistance was needed for eating/feeding and who would provide the services. Bathing assessed as mechanical help/ human help. The ISP did not document who would assist the resident with this assessed need. Resident #10?s ISP revised date 11-18-22 and date of admission noted as 10-4-22.
Plan of Correction:	1. Resident #2 ISP was updated to include who, when, and where stairclimbing and laundry services will be provided by the LPN on 5/1/23. Resident #10 ISP was updated to include the need for therapy services received on 3/16/23. 2. All residents? ISP?s will be audited to ensure that assessed needs and/or for significant change of resident?s condition. 3. Administrator/designee will educate the clinical staff on ensuring ISP?s include all assessed needs and where services will be provided. 4. Administrator/designee will audit 4 charts weekly for 8 weeks to ensure the ISP include assessed needs and significant changes in the residents? condition. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-680-M
Description:	Based on observation, record reviewed and staff interviewed, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 4-3-23 during the medication pass observation with staff #2, resident #4 had a physician?s order for Famotidine, Clotrimazole cream and Hydrocortisone cream. These medications were not available in the facility for the resident during the medication pass observation. 2. Resident #6 had a physician order for Ativan and Pramoxine suppositories. These medications were not available in the facility for the resident during the medication pass observation. 3. Staff #2 acknowledged the aforementioned residents? medications, suppositories, and creams were not available on the medication cart during the medication observation.
Plan of Correction:	1. Residents #4 and #6 currently have all prn ordered medications in the medication cart on 4/3/23. 2. Will conduct an audit on all residents ordered prn medications to ensure they are present in the medication cart. 3. Administrator/designee will educate clinical staff on ensuring medications ordered prn are available, properly labeled for the specific residents and properly stored. 4. Administrator/designee will conduct weekly audits for 8 weeks of all ordered prn medications for each resident to ensure they are available to administer. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.
Standard #:	22VAC40-73-990-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure that all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: 1. On 4-3-23, the facility?s resident emergency practice exercises, did not have documentation of staff members on the third shift (11p- 7a) participation. Staff #8 stated the practices are not being conducted with staff on the third shift. 2. Staff #1 and #8 acknowledged the resident emergency practices are not completed on all shifts.
Plan of Correction:	1. On 5/4/23 the third shift will participate in an exercise in which the procedures for residents? emergencies are practiced. 2. Emergency practice exercises will be conducted with staff on all shifts and documented quarterly. 3. Administrator/designee will educate the Security Manager on the standard of ensuring that all staff currently on duty on each shift shall participate in an exercise in which procedures for resident emergencies are practiced. 4. Administrator/designee will audit quarterly to ensure procedures for resident emergencies was practiced and documented. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 5/31/2023.