Riverside Assisted Living at Patriots Colony

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.

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.

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.

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.

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP

Based on record reviewed and staff interviewed, the facility failed to ensure the reviewed and updated individualized service plan ( ISP

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.

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

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.

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

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP

Based on record reviewed and staff interviewed, the facility failed to ensure the reviewed and updated individualized service plan ( ISP

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.

Based on observation and staff interviewed, the facility failed to ensure that medications ordered for PRN

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

Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan ( ISP

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.

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.

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP

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.

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.

Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s record included the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it within 30 days preceding admission. Evidence: 1. On 4-3-23, resident #1?s risk assessment was dated 1-12-23. The resident?s date of admission was documented as 12-6-22. 2. On 4-4-23, resident #3?s record did not include documentation of a risk assessment. Resident?s date of admission documented as 3-29-23. 3. Staff #1 acknowledged the aforementioned residents? record did not have admission risk assessments per the required admissions timeframe.

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.

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.

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

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.

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP

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

Based on observation, record reviewed and staff interviewed, the facility failed to ensure medications ordered for PRN

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.

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.

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

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.

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP

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.

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

Based on record review and staff interview, the facility failed to ensure the uniformed assessment instrument ( UAI

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 5-27-21, 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.

Based on record review and staff interview, the facility failed to ensure individualized service plan ( ISP