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 25, 2024 and March 28, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced renewal inspection conducted on 3-25-24 by two inspectors (Peninsula and Eastern Licensing Office). Ar 08:00/dep 16:50 p.m.) Census on day 1 was 45. Day two inspection conducted by one inspector (PLO). Ar 09:42/dep 15:30) 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 #:	22VAC40-73-250-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the staff record included verification of staff receiving a copy of staff?s job description. Evidence: 1. On 3-28-24, staff record review conducted with staff #1 and #8, staff #4 `s record did not include documentation of staff?s verification of current job description. Interview with staff #8, staff stated, staff #4 is sent an electronic reminder every Monday, Wednesday, and Friday. The staff?s date of hire noted as 2-5-24. 2. Staff #1 stated it is the role of Human Resources and Education to ensure all staff documentation is completed. 3. Staff #1 acknowledged staff #4?s record did not include documentation of staff?s verification of job description.
Plan of Correction:	1. Staff members # 1, 8, and 4 received a copy of their signed job description on 4/12/2024. 2. A 100% audit will be conducted by AL Director/designee of current staff records to include verification of staff receiving a copy of staff?s job description. 3. Administrator/designee will educate the hiring manager/designee on the requirement of ensuring staff records include verification of staff receiving a copy of staff?s job description. 4. Hiring manager/designee will audit 2 job descriptions weekly for 8 weeks to ensure the staff record included verification of staff receiving a copy of staff?s job description. 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 5/16/2024.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the assisted living facility did not admit or retain individuals with any prohibitive conditions. Evidence: 1. On 3-25-24, during the medication pass observation with staff #2, resident #1?s March 2024 medication administration record (MAR) noted resident prescribed Clonazepam (Klonopin) 0.5 mg. as needed (PRN) for anxiety, start date noted as 11-22-23. 2. Staff #1 acknowledged the resident?s record did not include a psychotropic treatment plan for the prescribed Clonazepam (Klonopin).
Plan of Correction:	1. Resident #1 Psychotropic treatment plan was updated by the AL Director to include Clonazepam on 3/25/2024. 2. All residents receiving psychotropic medications will be audited to ensure that the resident has a psychotropic treatment plan for each medication ordered. 3. Administrator/designee will educate the clinical team of the requirement that all psychotropic medications must have a psychotropic treatment plan. 4. Administrator/designee will audit 3 residents weekly for 8 weeks to ensure that if the resident receiving psychotropic medications to ensure there is a psychotropic treatment plan for the medication. 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 5/16/2024.
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 3-25-24, resident #1?s uniformed assessment instrument (UAI) dated 11-8-23 noted toileting need assessed as mechanical help/human help/physical assistance (mh/hh/pa). The ISP dated 11-8-23 noted ?toileting does need help?. Eating/feeding need assessed as human help/supervision (hh/s). The ISP noted ?does need help?. Walking assessed as mh/hh/pa. The ISP noted ?mechanical help and human physical help is needed-uses walker?. Stairclimbing assessed as mh/hh/pa. The ISP noted ?mechanical and human physical help is needed?. Mobility assessed as mh/hh/pa. The ISP noted ?mechanical and human help physical: uses wheelchair for distances?. Orientation assessed as disoriented some spheres all the time to time and place. The ISP noted, ?offer to call family?. 2. Resident #3?s UAI dated 1-31-24 noted bathing need assessed as mechanical help/human help/supervision (mh/hh/s). The ISP dated 2-14-24 noted ?bathing does not need help?. Transferring assessed as mh. The ISP noted ?mechanical help? no mechanical device noted. Walking assessed as mh. The ISP noted ?mechanical help is needed?, no mechanical device noted. Mobility assessed as mh. The ISP noted ?requires mechanical help?, no mechanical device noted. Medication assessed as administered by facility staff. The ISP need did not include who, what, when, where or goal for this assessed need (area of document is blank). 3. Resident #4?s UAI dated 1-13-24 noted walking need assessed as not performed. The ISP noted ?walking: mechanical help is needed. Walker and electric scooter, manual wheelchair?. Wheeling assessed as no help needed. The ISP noted ?wheeling: mechanical help is needed. Uses electric scooter and a manual wheelchair elevated by PT for safety?. Dressing assessed as no help needed. The ISP noted ?does need help, shoehorn to help apply shoes?. Mechanical help. Assessed needs did not match ISP care needs. 4. Staff #1 acknowledged the resident?s assessed needs and the ISPs of the residents do not match or document the ISP requirements.
Plan of Correction:	1. Resident #1?s ISP was updated by the AL Director on 4/9/2024 to include what type of assistance was needed for toileting, eating, walking, stairclimbing, and mobility. Resident #3?s ISP was updated by the AL Director on 4/9/2024 to include what type of mechanical device was needed for walking, bathing, and transferring. Resident #4?s UAI was updated by the AL Director on 4/9/2024 for walking and wheeling to be assessed as mechanical help. 2. All residents? ISP will be audited to ensure the service 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 5/16/2024.
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or the legal representative. Evidence: 1. On 3-25-24, resident #1?s individualized service plan (ISP) completed 11-8-23 was not signed and dated by the resident nor the resident?s legal representative. 2. Staff #1 stated the resident?s caregiver, C-1 signed for the resident?s representative. Staff did not have documentation from the resident?s representative authorizing C-1 to sign resident?s ISP. 3. Staff #7 provided the inspectors with documentation of the representative?s verbal consent. This note was written on 3-25-24 following, the inspector?s conversation with staff #1 regarding no documentation of consent in the resident?s record. 4. Staff #1 acknowledged the facility did not have written consent for C-1 to sign the resident?s ISP and the ISP was not signed and dated by the resident?s legal representative.
Plan of Correction:	1. Resident #1 individual service plan was updated and signed by the POA on 3/25/2024. 2. All residents? ISPs will be audited to ensure that they have been signed and dated by the resident or legal representative. 3. Administrator/designee will educate staff on ensuring the ISP is signed and dated by the resident or legal representative. Written consent must be obtained for others to sign the ISP and dated by the resident or legal representative. 4. Administrator/designee will audit 4 charts weekly for 8 weeks to ensure the ISP is signed and dated by the resident or legal representative. 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 5/16/2024.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the reviewed and updated individualized service plan (ISP) documented resident?s assessed needs. Evidence: 1. On 3-25-24, resident #5?s UAI dated 9-18-23 noted transferring assessed as mechanical help (mh). The ISP revised on 1-15-24 did not include transferring need. 2. Resident #7?s UAI dated 10-05-23 noted walking assessed as no help needed. The ISP revised on 10-12-23 noted ?resident does not need help?walking: human help physical is needed?. Wheeling assessed as mechanical help/human help/physical assistance (mh/hh/pa). The ISP noted ?wheeling: human help physical is needed?. ISP noted ?abusive/aggressive/disruptive -less than weekly?redirect: familiar topics?. The UAI did not include an assessment for abusive/aggressive/disruptive behaviors. 3. Staff #1 acknowledged, the residents? UAI and ISP did not match and/or included all elements required for the ISP.
Plan of Correction:	1. Resident #5 ISP was updated by the AL Director to include type of mechanical assistance is needed for transfers on 4/9/2024. Resident # 7 ISP was updated by the AL Director to include they do not need help walking, wheeling needs physical and mechanical assistance, and uses manual wheelchair pushed by staff. 2. All residents? ISP?s will be audited to ensure that assessed needs on the UAI match the needs listed in the ISP. 3. Administrator/designee will educate the clinical staff on ensuring ISPs 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 5/16/2024.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 3-25-24, the menu observed posted on the safe, secure unit was ?week 1? and did not include the current date of 3-25-24. 2. Staff #1 and #9 acknowledged the menu posted did not reflect the current date of 3-25-24.
Plan of Correction:	1. The menu on the safe, secure unit was posted with the correct week by the AL Director on 3/26/24. 2. Will audit all menus posted on the safe, secure unit to ensure that the correct week and date is posted. 3. Administrator/designee will educate the dining services teams on the importance of checking that the menu posted has the correct week and date to reflect the current menu cycle. 4. Administer/designee will audit 3 times weekly on the safe and secure unit for 8 weeks to ensure the menus posted reflect the current week and date. The results of the audit will be reported at the COR meeting for evaluation of compliance and ongoing monitoring continuous improvement. 5. All corrective action will be completed by 5/16/2024.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interviewed, the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 3-25-24 during the medication pass observation with staff #4, resident #6?s Saline Nasal Spray Solution for dry nose was not available on the cart. Staff #1 assisted staff in searching for the nasal spray by checking the medication cart and the treatment cart located in the nurse?s station. 2. Staff #1 acknowledge resident #6?s PRN Saline Nasal Spray was not available in the facility.
Plan of Correction:	1. Resident #6 prn nasal spray was replaced by the AL Director on the medication cart on 3/26/2024. 2. Will audit all medication carts to ensure prn medications are available, properly labeled and store on the medication cart. 3. Administrator/designee will educate clinical staff on ensuring medications ordered prn are available, properly labeled for the specific resident, and safely 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 5/16/2024.
Standard #:	22VAC40-73-700-1
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when oxygen therapy is provided, the facility shall have a valid physician?s or other prescriber?s order that includes the oxygen source, delivery, and flow rate. Evidence: 1. On 3-25-24, resident #8?s ISP documented resident?s use of oxygen ?continuous oxygen at bedtime only at 2 liters/m via nasal cannula?. The information noted on the ?order audit report? provided to the inspector noted ?Oxygen at 2 LPM?. The facility?s record did not have a physician?s order that included the delivery source. 2. Staff #1 acknowledged, the physician?s order in the record did not include all the requirements for oxygen order in assisted living facilities.
Plan of Correction:	1. Resident #8 Oxygen order was updated by the AL Director to include oxygen to be administered via nasal cannula on 3/25/2024. 2. Will conduct an audit on all resident receiving oxygen to ensure that the physician order contain the method of administration. 3. Administrator/designee will educate the clinical staff on ensuring oxygen therapy is provided with a valid order to include oxygen source, delivery route and flow rate. 4. Administrator/designee will conduct weekly audits for 8 weeks to ensure that all oxygen orders include the route of administration. 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 5/16/2024.