VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: March 11, 2025 and March 12, 2025

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 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

830-F: Resident council 990-C- Emergency preparedness plan

Comments:

Type of inspection: Renewal An on-site renewal inspection was conducted by two licensing inspectors from Peninsula and Central Licensing Office on 3-11-25 (Ar 07:23 a.m./dep 17:20 p.m.) on day 1. On day 2- one inspector (Ar 09:27 a.m./dep 13:40 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 10 Observations by licensing inspector: medication pass, breakfast meal, emergency preparedness, first aid kit Additional Comments/Discussion: 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 #:	22VAC40-73-1110-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the prior to admitting a resident with 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. Evidence: 1. On 3-11-25, resident 3?s approval for placement in the facility?s safe, secure unit was documented by staff #1 but the date was not documented. Prior to placement could not be determined. 2. Staff #1 acknowledged the resident?s approval document by the facility did not have a date.
Plan of Correction:	1. Resident #3 Approval for placement in the facility's safe and secure units was dated and placed in the resident's chart on 3/11/2025 by the administrator. 2. 100% audit of all residents' approval for placement living in the safe and secure unit have been signed and dated by the director/ designee. 3. Educated Assisted Living director on regulation to date and sign approval for placement in a safe and secure unit. 4. Will audit all new admissions monthly for 8 weeks to ensure that the approval for placement on the safe and secure unit has been signed and dated by the Assisted Living director. 5. All corrective action will be completed by 5/20/2025
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. On 3-11-25, the Resident Program Staff schedule provided for January, February and March 2025 noted only the first name of staff and no department or job classification. Dietary staff schedule did not include job classification. 2. Staff #1 acknowledged the department schedules did not include all required information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the preceding admission physical examination included all required information for admission. Evidence: 1. On 3-11-25, resident #3?s preadmission physical examination dated 5-8-24 documented the resident ?required continuous licensed nursing care, needs continuous supervision?. 2. Staff #1 acknowledged the resident?s physical examination did not meet assisted living criteria.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertained and the date the information was obtained. Evidence: 1. On 3-12-25, resident #6, record documented the sex offender information was ascertained on 11-13-24. The resident?s date of admit to the facility was noted as 11-7-24. 2. Staff #1 acknowledged the resident?s sex offender information was not ascertained prior to admission to the assisted living facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 required information. Evidence: 1. On 3-11-25, resident #3?s uniformed assessment instrument (UAI) dated 5-9-24 noted bowel need assessed as less than weekly and bladder need assessed as greater than weekly. The ISP dated 5-9-24 did not document resident?s use of adult briefs for incontinence. The resident?s transferring need assessed as mechanical help/physical assistance. The resident?s ISP noted resident?s use of a wheelchair to transfer onto the toilet. Staff #1 stated resident does not use a wheelchair. 2. Staff #1 acknowledged the resident?s ISP did not include all required care needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
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) included all required information. Evidence: 1. On 3-11-25, resident #1?s uniformed assessment instrument dated 5-2-24 noted the resident was disoriented some spheres (time, place, situation), some time. The ISP dated 5-2-24 noted resident to be reorientation, how the services were to be provided was not documented. 2. Staff #1 acknowledged the resident?s ISP did not include all required information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure any menu substitution or additions was recorded on the posted menu. Evidence: 1. On 3-11-25, the posted menu in the safe, secure unit did not document the change of orange slices to include the fruit cup observed being served during the breakfast meal. 2. Staff #7, preparing the meal acknowledged the orange slices were not available and the fruit cup was substituted. Staff was shown the menu which was not changed to reflect the substitution.
Plan of Correction:	1. On 3/11/2025, no residents or RR's voiced complaints of substitution to include fruit cups for breakfast. 2. Posted menus have been audited daily for substitution. 3. Director /designee will educate the dining services teams on the importance of posting substitution when an item on the menu is not available. 4. Director /designee will audit 3 times weekly on the safe and secure unit for 8 weeks to ensure the menus posted have all the items listed, and substitution documented appropriately. 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 5/20/2025.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interviewed, the facility failed to ensure when medications and dietary supplements are prescribed for residents and are administered by the facility, medications will be stored in a medicine cabinet, container, or compartment that is locked. Evidence: 1. On 3-11-25 during the medication pass observation with staff #2 on the facility?s safe, secure unit, resident # 7?s Eucerin cream was observed on a table in the resident?s room. The resident?s physician?s order noted the cream was prescribed on 2-7-25. The resident #7?s uniform assessment instrument (UAI) dated 1-28-25 documented resident?s medication is administered by nursing staff. 2. Staff #1 acknowledged the resident?s medication should be stored on the facility?s medication cart and not in the resident?s room.
Plan of Correction:	1. Eucerin cream was removed from the residents by the staff on 3/11/2025. 2. Director /designee will conduct a 100% audit of all Memory care residents' room to ensure that there are no creams that have a been ordered by the physician are secured on the medication cart. 3. Director/ designee will educate the staff and notify the families that creams that have been ordered by the physician cannot be left in a resident's room and must be placed on the medication cart. 4. Director /designee will audit 2 rooms weekly for 8 weeks to ensure that there are no creams that have been ordered by the physician are in the resident's room. 5. All corrective actions will be completed by 5/20/2025.