Virginia DSS · Assisted Living Facility

Riverside Assisted Living at Patriots Colony

📍 6200 Patriots Colony Drive, Williamsburg, VA, 23188

ID 20066Two Year licenseActive
9
Inspections
On record
9
With violations
Visits that cited something
0
Clean visits
Nothing cited
41
Violations cited
Individual findings
26
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Riverside Assisted Living at Patriots Colony was inspected 9 times between September 29, 2020 and April 13, 2026 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 0 with none. Across that history VDSS cited 41 violations under 26 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 7 of these 9 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
06/13/2028
Administrator
Shanita Lowery
Licensing inspector
Darunda Flint
Inspector phone
(757) 807-9731
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

9

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

April 13, 2026Inspection1 violation
Inspection dates
04/13/2026, 04/28/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-970
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/13/2026 ( arrival 9:50 a.m. / departure 2:44 p.m.) and 04/28/2026 (arrival 10:45 am / departure 2:50 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: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch was observed. A medication pass observation was completed for four residents. The following were reviewed: emergency preparedness drills, fire inspection report, health inspection report, first aid kit, and water temperatures were measured and an activity was observed. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-430-H-2
Based on record reviewed, the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contains the reason or reasons for the discharge, and a copy of the written statement shall be retained in the resident's record
Evidence
  1. Staff #2 and staff #3 acknowledged there was no discharge documentation for resident #5. Resident #5’s discharge date was documented as 12/24/2025.
Plan of correction
1. Resident #5 no longer resides in the facility as of December 24, 2026. Immediately upon identification of the citation, the Director completed the required discharge instruction form for Resident #5, including a written discharge statement identifying the reason for discharge. The discharge documentation was dated, signed, and placed in the resident’s EMR record to achieve compliance. 2. 100% audit will be completed of all residents who have been discharged since January 1, 2026, to ensure discharge dates, signatures and completion of form is completed. The facility has reimplemented a standardized Discharge Instruction Form that will be used for all resident discharges moving forward. This form must be completed, dated, and signed by the Director or designee at the time of discharge and stored in EMR. Records will not be finalized until all discharge requirements are verified. 3. The Director/ designee will provide education to the administrative and supervisory staff responsible for resident records to include reviewing the current DSS regulation and proper completion and retention of the discharge instruction form. • Review of regulatory requirements under 22VAC40 73 430 H • Proper completion and retention of the discharge instruction form Education will be documented and reinforced during ongoing staff meetings. 4. The Director/designee will audit all resident discharges monthly for three (3) months to verify completion of the discharge form, appropriate signatures, dates and that the document is in the EMR. The results of the findings will be reviewed at the QA meeting for tracking and trending. a. Completion of the discharge form b. Appropriate signatures and dates c. Retention of documentation in the resident record After three months of sustained compliance, audits will continue quarterly. All audit findings will be documented. If deficiencies are identified, corrective action will be taken immediately.
March 11, 2025Inspection8 violations
Inspection dates
03/11/2025,03/12/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 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
22VAC40-73-290-A
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 published by VDSS.
22VAC40-73-450-F
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 published by VDSS.
22VAC40-73-660-A
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.
22VAC40-73-450-C
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 published by VDSS.
22VAC40-73-350-B
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 published by VDSS.
22VAC40-73-610-B
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.
22VAC40-73-1110-A
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
22VAC40-73-320-A
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 published by VDSS.
March 25, 2024Inspection8 violations
Inspection dates
03/25/2024; 03/28/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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
22VAC40-73-450-F
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.
22VAC40-73-450-E
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.
22VAC40-73-450-C
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.
22VAC40-73-310-H
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.
22VAC40-73-610-B
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.
22VAC40-73-680-M
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.
22VAC40-73-700-1
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.
22VAC40-73-250-C
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.
December 12, 2023Complaint survey1 violation
Inspection dates
12/12/2023;01/29/2024;02/02/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced complaint inspection was conducted on 12-12-23. Ar 10:42 a.m./ Dep 13:25 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10-25-23 regarding allegations in the areas of resident care and related services. Number of residents present at the facility at the beginning of the inspection: Census 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 8 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 some, but not all of the allegation; area(s) of non-compliance with standard(s) or law A violation notice was issued; any violation(s) not related to the complaint 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
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) was reviewed and updated.
Evidence
  1. On 12-12-23, during a complaint inspection, resident #1’s individualized service plan (ISP) provided to the inspector by staff #1 was not updated. The target date for the resident’s goals were dated 3-31-23. The resident’s progress notes documented cognitive changes for the resident. The facility’s 72-Hour Summary also documented cognitive changes. The resident’s Progress notes documented the following: (a) On 12-21-22 at 12:01, staff was assisting resident with shower, when staff observed resident removing undershirt and disposed of the shirt in the toilet and closed the lid. Staff removed the shirt from toilet. (b) On the morning of 12-24-22 at 12:06, it was noted, the resident was walking towards the entrance of the building with a coat on and only an underdress slip underneath. It was noted resident stated going out with family and that is what resident wanted to wear. Note documented several staff members tried reasoning with resident because of what resident was wearing and the extreme cold temperature. (c) On 1-3-23, resident observed attempting to go to the dining room in a cardigan and night gown and not wearing any undergarments. Staff tried to reason with staff regarding dressing appropriately for the dining room. Resident did change outfit. (d) 1-16-23 noted facility staff communicating with resident’s POA, the resident’s service plan and level of care reviewed via telephone. The note indicated, due to continued and steady cognitive decline, resident is requiring more care needs to be meet by staff. Level of care was increased to a 83 for this reason. POA voiced understanding and also stated noticing the cognitive decline. (e) On 2-6-23 at 11: 53, resident observed attempting to enter the dining room in a bathrobe and night gown, redirected to go back upstairs to dress appropriately. (f) On 6-1-23, staff contacted family member to discuss staff concerns, resident refusing to wear or change briefs and not wanting to dirty laundry or linens to be washed, voice message left. (g) On 7-31-23 at 06:18, staff documented resident came to nurse’s station at 0030 and was confused about time and making remarks that did not make sense. Resident came again at 03:15, when asked, resident denied having trouble sleeping. Resident stated wanting to go downstairs and see “how it is outside”. Resident returned to 10 minutes later but did not sleep and was awake. (h) 9-6-23, staff noted, resident confused but calm and cooperative. (i) 9-9-23 staff noted, resident showing more signs of confusion or not comprehending; did not remember that resident usually get a croissant for breakfast daily and eats in room. (j) 9-13-23, resident did not know what resident’s key was or how to use; resident seems more confused than normal. (k) On 9-16-23 at 06:32, staff noted resident showing increased confusion, came to nurse’s station three times asking the same question. Resident also wandering around unconvinced about the time of day; went to check if breakfast was being served at 23:30. (l) On 9-16-23 at 18:58, staff documented, resident dementia is worsening. Resident is not eating; staff in the dining room report having to cue resident to eat. Resident takes one bit than voice being full. Resident unaware of time anymore, continuously going to the dining room asking for lunch all times of the day. (m) On 9-24-23, resident not aware of bowel movement in brief, resident changed by staff and assisted with night clothes and prepare for bed. (n) On 10-1-23 staff noted resident required extensive encouragement for all 3 meals; drank small amount of boost and ate small bites of meals.
Plan of correction
1. Resident #1 no longer resides in the facility as of October 4, 2023. 2. All residents' ISP's will be audited to ensure that any cognitive changes, weight loss and any changes in care needs are updated accordingly. 3. Administrator/designee will educate the clinical staff on ensuring the ISPs include all cognitive changes, weight loss and any changes in care needs and services to be provided. 4. Administrator/designee will audit 4 charts weekly for 8 weeks to ensure the ISPs include any cognitive changes, weight loss and assessed needs in the resident's condition. The results of the audit will be reported to the clinical operations report for evaluation of compliance and ongoing monitoring for continuous improvement. 5. All corrective actions will be completed by March 29, 2024.
September 21, 2023Inspection3 violations
Inspection dates
09/21/2023;10/25/2023;11/01/2023;11/09/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 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
22VAC40-73-320-A
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
22VAC40-73-450-C
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.
22VAC40-73-70-A
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.
April 3, 2023Inspection11 violations
Inspection dates
04/03/2023,04/04/2023,04/28/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 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
22VAC40-73-350-B
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.
22VAC40-73-380-B
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.
22VAC40-73-450-C
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.
22VAC40-73-450-F
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.
22VAC40-73-320-A
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
Evidence
  1. d 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:
  2. 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.
  3. 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.
  4. 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.
22VAC40-73-390-A
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.
22VAC40-73-990-C
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.
22VAC40-73-1110-A
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.
22VAC40-73-1100-A
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.
22VAC40-73-410-A
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.
22VAC40-73-680-M
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.
April 5, 2022Inspection6 violations
Inspection dates
04/05/2022; 04/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Comments
An unannounced renewal inspection was conducted on 4-5-22 and 4-6-22 by two inspectors from the Peninsula Licensing Office. The facility census on 4-5-22 was 63. A tour of the assisted living and safe, secure unit was conducted with staff from the nursing center. A medication pass observation was conducted on both units, resident and staff interviews were conducted, emergency preparedness material were reviewed, breakfast was observed on the ALF unit and the first aid kits were checked for compliance. A review of issues, concerns, violations were reviewed with staff throughout the inspection process. An exit was conducted with the Administrator and Manager. The acknowledgement form was sent via email and signed by the administrator following the exit. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days (4-24-22).
Violations
22VAC40-73-1180-B
Based on observation and staff interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. On 4-5-22 during a tour of the safe, secure unit with staff #10 and #11 the following items were observed in resident #5’s bathroom: hand- sanitizer, two tubes of protective ointment, shampoo and a bar of soap.
  2. Staff #10 and #11 acknowledged the items were in the resident’s bathroom.
Plan of correction
Not published by VDSS.
22VAC40-73-710-B
Based on record observation, record reviewed and staff interviewed, the facility failed to ensure a medical restraint would only be used according to a physician’s written order and the written consent of the resident or the legal representative.
Evidence
  1. On 4-5-22 during a tour of the safe, secure unit (SCU), a type of bedrail was observed on resident #1’s bed. The resident could not demonstrate the use of the rail, but stated it was for “safety”. The resident continue to repeat the word “safety” and became agitated by the questions and want to go and complete a crossword book.
  2. The resident’s individualized service plan (ISP) dated side-rails were in place for positioning. The record did not include a physician’s written order nor the written consent of the legal representative for the side-rails. The ISP noted for the side-rails the staff would provide services.
  3. On 4-5-22 and 4-6-22 during the exit meeting, staff #1 and #2 acknowledged the facility did not have the required documents from the legal representative physician for the side-rail.
Plan of correction
Not published by VDSS.
22VAC40-73-380-A
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 five of seven residents were obtained and kept current in the residents’ records.
Evidence
  1. Resident #4’s personal and social information document noted the resident as “Full Code”. The resident’s record included a “POST” document which noted resident preference as “Do Not Resuscitate”. The “POST” document was signed and date by the physician on 5-29-20. The social and personal document was not updated to reflect resident’s current status in the event of cardiac or respiratory arrest.
  2. Resident #1’s record did not include a personal and social information document. The resident’s date of admission was documented as 7-16-21.
  3. Resident #3’s record did not include a personal and social information document. The resident’s date of admission was documented as 12-10-20.
  4. Resident #5’s record did not include a personal and social information document. The resident’s date of admission was documented as 2-15-22.
  5. Resident #6’s record did not include a personal and social information document. The resident’s date of admission was documented as 1-31-22.
  6. On 4-5-22 and 4-6-22 during the exit meeting, staff #1 and #2 acknowledged the aforementioned residents’ record did not include the personal and social data information and resident #4’s social data form was not updated to reflect DNR status.
Plan of correction
Not published by VDSS.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for four of seven residents.
Evidence
  1. Resident #3’s April 2022 medication administration record (MAR) documented resident prescribed Lorazepam. The treatment plan dated 1-27-22 did not include this include this psychotropic medication.
  2. Resident #4’s April 2022 MAR documented resident prescribed Haldol and Xanax. The treatment plan dated 2-18-22 did not include these psychotropic medications.
  3. Resident #5’s February 2022 MAR documented resident prescribed Seroquel and Lorazepam. The treatment plan dated 4-5-22 did not include these psychotropic medications.
  4. Resident #7’s February 2022 MAR documented resident prescribed Lorazepam. The treatment plan dated 1-27-22 did not include this psychotropic medication.
  5. On 4-5-22 and 4-6-22 during the exit meeting, staff #1 and #2 acknowledged the aforementioned residents’ psychotropic treatment plans did not include all psychotropic medications.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on observation and staff interviewed, the facility failed to monitor the medication cart to ensure it prevented the use of outdated, damaged, or contaminated medications.
Evidence
  1. On 4-5-22 during the medication pass observation with staff #3, resident #3’s Epipen’s label noted the pen was to be discarded 3-31-22. The Epipen remained on the cart until the inspector inquired about expired items on the medication cart.
  2. Staff # 3 acknowledged the Epipen had expired and was on the medication cart on 4-5-22 during the medication observation.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of seven residents.
Evidence
  1. Resident #4’s record documented hospice services, dated 3-9-22 was being provided. The individualized service plan (ISP) dated 3-14-22 did not include what hospice services were provided. The ISP also documented psychological services but did not include who and when psychological services were being provided.
  2. Resident #6’s uniformed assessment instrument (UAI) dated 9-24-21 documented dressing need assessed as physical assistance. The ISP dated 9-26-21 did not document the type of assistance needed.
  3. On 4-5-22 and 4-6-22, staff #1 and #2 acknowledged the aforementioned residents’ ISP did not include all assessed needs.
Plan of correction
Not published by VDSS.
May 21, 2021Inspection2 violations
Inspection dates
May 21, 2021 , May 24, 2021 , May 27, 2021 and June 2, 2021
Areas reviewed
Part III: PERSONNELPart IV: STAFFING and SUPERVISIONPart V: ADMISSION, RETENTION AN DISCHARGE OF RESIDENTSPart VI: RESIDENT CARE AND RELATED SERVICESPart IX: EMERGNECY PREPAREDNESSPart 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
22VAC40-73-440-D
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
22VAC40-73-650-A
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- ?s ut t o epo t dated docu e ted es de t ece ed oost as des ed at east t ce a day. O 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
September 29, 2020Inspection1 violation
Inspection dates
Sept. 29, 2020 , Sept. 30, 2020 , Oct. 1, 2020 , Oct. 5, 2020 and Oct. 7, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 9-29-20; 9-30-20; 10-1-2020 and concluded on 10-7-2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 57. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, fire and health inspection, nutrition and health care oversight documents, fire and emergency drills, and staff staff schedules submitted by the facility to ensure documentation was complete. 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
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure individualized service plan (ISP) contained all assessed needs for three of four resident records.
Evidence
  1. During the remote monitoring inspection, a review of resident #1's record, the uniformed assessment instrument (uai) dated 3-18-20 noted eating/feeding was not a need; however, a review of the individualized service plan (ISP) dated 3-18- 20 noted meal preferences indicated resident #1 needed "cueing, reminder to meals, need encouragement at mealtime for nutrition. Further review of the uai noted mobility need: mechanical help/human help/supervision, however, the ISP noted "cues/ coaxing to go outside, no mechanical help noted.
  2. A review of resident #2's recent uai dated 9-28-20 noted, mechanical help need, however, the ISP dated 9-28-20 noted resident did not need help and was not documented as a need on the ISP. Further review of the ISP noted resident's diet needs indicated no restrictions, however, resident #2's physical examination dated 8-29-20 noted soft food and no excess sugar. A review of the resident's signed physician's order dated 9-14-20 noted a "NAS/RCS" diet. This assessed need was not included on resident #2's recent ISP dated 9-28-20 presented for review during the monitoring inspection.
  3. A review of resident #4's uai dated 4-7-20 indicated toileting need assessed as mechanical help/human help/supervision, however, the ISP dated 4-7-20 noted “bedside toilet” and resident providing services; supervision assessment not documented on ISP. Stairclimbing need assessed as mechanical help/human help/supervision, however, the ISP noted handrail services and staff to provide services. The ISP dated 4-7-20 provided for inspector's review did not include what type of supervision help was needed. Further review of the uai also noted resident #2's need for assistance with instrumental activities of daily living (iadls): meal preparation, money and housekeeping, however, these iadls needs were not care planned as to who would provide services, where, when, and what services were provided. Another iadl- laundry need was assessed, however, the ISP did not include who, when and where the services would be provided. Also a review of resident #4's ISP noted no diet restrictions, however, resident #4's physical examination dated 4-7-20 noted NAS (no added salt) diet need.
  4. Staff #1 and #2 acknowledged the resident's ISP did not include all assessed needs for resident's records reviewed during the monitoring inspection on 10-7-20 during the exit interview.
Plan of correction
Not published by VDSS.