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: Sept. 21, 2023 , Oct. 25, 2023 , Nov. 1, 2023 and Nov. 9, 2023

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 63.2 PROTECTION OF ADULTS AND REPORTING 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Other An on-site self-report complaint inspection was conducted on 9-21-23 (AR 13:48 Dep 17:00). The facility census was 66. 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 (9-1-23) regarding allegation of staff abuse/neglect of a resident on 8-17-23. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. N/A 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: 6 Observations by licensing inspector: Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757)- 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on documented reviewed and staff interviewed, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. Evidence: 1.On 9-1-23, the licensing inspector received an incident report for resident #1. The initial report noted a negative interaction between resident #1 and staff #4 occurred on 8-13-23. The final report noted the administrator was informed on the incident on 8-17-23 of the incident. 2. On 9-21-23, staff #1 acknowledged not reporting the incident to the licensing office within 24 hours.
Plan of Correction:	1. The Administrator / Designee will educate on mandated reporting to including time sensitivity of reporting incidents, abuse prevention and facility reporting policy and procedures. 2. The Administrator/ Designee will do random audits weekly for 4 weeks of 5 staff members regarding their knowledge of reporting of incident to evaluate any educational needs of the staff as it pertains to facilities reporting requirements. 3. The Administrator /Designee will interview 2 residents/ families weekly for 4 weeks to ensure their needs are being met and that there are no concerns regarding care. 4. The results of the audits and actions taken based on resident feedback or reports as well as staff audit will be reported at the Clinical Operations Review meeting including any reportable incidents, analysis, trends and action plans. 5. All corrective actions will be completed by 12/10/2023.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding the admission, a person shall have a physical examination by an independent physician. Evidence: 1. On 9-21-23, resident #1?s physical examination record was dated 1-10-23. The record noted the resident?s date of admission was 2-15-23. 2. Staff #1 acknowledged the resident?s physical examination was older than 30 days and no other notation from the medical individual who signed and dated the physical examination.
Plan of Correction:	1. Resident #l's History and Physical was acknowledged to be 5 days past the 30 days prior to admission as required by the Standard for Assisted Living Facilities 2. Administrator/ Designee will educate the marketing, admissions, and nursing staff on the requirement that the History &Physical be competed not greater then 30 days prior to date of admission, 3. Marketing/ Admission designee will review preadmission information to ensure that the History & Physical examination is completed within the required time frame an aligns with admission date not to be older than 30 days 4. Administrator/ designee will audit all new admissions for 3 months to ensure that the History and Physical examination is completed and dated no more than 30 days prior to admission. The results of the audits will be reported at the Clinical Operations Review meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 12/10/2023
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 a resident. Evidence: 1. On 9-21-23, resident #1?s uniformed assessment instrument (UAI) dated 2-1-23 noted bathing need assessed as mechanical help/human help/physical assistance. The individualized service plan (ISP) noted initial assessment mechanical help/physical assistance on 2-1-23. The ISP also noted bathing need revision on 7-13-23. The bathing need was revised to mechanical help and human supervision. Dressing need assessed as human help/physical assistance. The ISP noted initial help- physical assistance on 2-1-23. The ISP noted on 3-27-23, dressing need revised to human supervision. Eating/Feed assessed as no help needed. The ISP noted resident has diet restrictions needs and does need help. The help needed is not documented. The resident?s clinical notes/progress notes provided by staff #4 on 9-21-23 noted the resident receiving mental health services. This info was not documented on the resident?s ISP. 2. Staff #2 acknowledged all assessed needs for the resident was not documented on the resident?s ISP.
Plan of Correction:	1. Resident #1's ISP was updated on 11/10/2023 to include the to include the bathing and dressing need as mechanical and physical help be provided as assessed by the UAL Eating and Feed updated on the ISP as no assistance needed per the UAL Mental health services were added to the ISP to reflect the resident being provided those services. 2. All residents' ISPs will be audited to ensure that the plan includes all assessed needs of each resident. 3. Administrator/ designee will educate the clinical team on the requirements of the ISP to include all assessed needs and services being provided for the resident. 4. Administrator/ designee will audit 4 residents ISP's weekly for 8 weeks to ensure that the ISP includes all assessed needs of the residents and services provided. The results of the audit will be reported at the Clinical Operations Review meeting for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by 12/10/2023.