Inspection Reports for Riverside Assisted Living at Patriots Colony
6200 Patriots Colony Drive, VA, 23188
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
63 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 63
Deficiencies: 8
Mar 11, 2025
Visit Reason
An on-site renewal inspection was conducted by two licensing inspectors from Peninsula and Central Licensing Office on March 11 and 12, 2025 to assess compliance with applicable standards and regulations for license renewal.
Findings
The inspection determined non-compliance with several applicable standards and laws, resulting in documented violations. The licensee was given the opportunity to submit a plan of correction to address the cited violations and maintain future compliance.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure prior to admitting a resident with serious cognitive impairment due to dementia, placement in the special care unit was appropriately determined and documented. |
| Facility failed to ensure the written work schedule included names and job classifications of all staff working each shift, with indication of who is in charge. |
| Facility failed to ensure the preceding admission physical examination included all required information for admission. |
| Facility failed to ascertain and document whether a potential resident is a registered sex offender prior to admission when length of stay is greater than three days. |
| Facility failed to ensure the individualized service plan (ISP) included all required information for resident #3. |
| Facility failed to ensure the reviewed and updated individualized service plan (ISP) included all required information for resident #1. |
| Facility failed to ensure any menu substitution or additions was recorded on the posted menu. |
| Facility failed to ensure medications and dietary supplements prescribed for residents and administered by the facility were stored in a locked medicine cabinet or compartment. |
Report Facts
Number of residents present: 63
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
Inspection Report
Renewal
Census: 45
Deficiencies: 8
Mar 25, 2024
Visit Reason
An unannounced renewal inspection was conducted on March 25 and March 28, 2024, to assess compliance with applicable standards and laws for license renewal of the assisted living facility.
Findings
The inspection found multiple violations including failure to verify staff job description receipt, lack of psychotropic treatment plans, incomplete individualized service plans (ISP), unsigned ISPs, missing medications, undated menus, and incomplete oxygen therapy orders. Corrective actions and audits were planned to address these deficiencies.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure staff record included verification of staff receiving a copy of staff's job description. |
| Facility failed to ensure the assisted living facility did not admit or retain individuals with any prohibitive conditions, specifically missing psychotropic treatment plan for prescribed medication. |
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs for residents. |
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or the legal representative. |
| Facility failed to ensure the reviewed and updated individualized service plan (ISP) documented resident's assessed needs. |
| Facility failed to ensure the menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents. |
| Facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. |
| 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. |
Report Facts
Census: 45
Inspection Dates: 2
Plan of Correction Completion Date: 2024
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Dec 12, 2023
Visit Reason
An unannounced complaint inspection was conducted on December 12, 2023, following a complaint received on October 25, 2023, regarding allegations in the areas of resident care and related services.
Findings
The investigation supported some but not all allegations of non-compliance. A violation was found related to failure to ensure that a resident's individualized service plan (ISP) was reviewed and updated according to documented cognitive changes.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, with evidence supporting some areas of non-compliance related to resident care and individualized service plan updates.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the resident's individualized service plan (ISP) was reviewed and updated despite documented cognitive changes and care needs. |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 1
Number of staff interviews conducted: 8
Plan of correction audit frequency: 4
Plan of correction completion date: Mar 29, 2024
Inspection Report
Census: 66
Deficiencies: 3
Sep 21, 2023
Visit Reason
An on-site self-report complaint inspection was conducted due to a self-reported incident received by VDSS Division of Licensing regarding an allegation of staff abuse/neglect of a resident on 8-17-23.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Additional violations not related to the self-report were also identified during the investigation.
Complaint Details
The visit was complaint-related based on a self-reported incident alleging staff abuse/neglect of a resident on 8-17-23. The evidence gathered supported the non-compliance and violations were issued.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure within 30 days preceding admission, a person had a physical examination by an independent physician. |
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs for a resident. |
Report Facts
Number of residents present: 66
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
Corrective action completion date: Dec 10, 2023
Inspection Report
Renewal
Census: 64
Deficiencies: 10
Apr 3, 2023
Visit Reason
On-site renewal inspection conducted on April 3, 4, and 28, 2023 to assess compliance with applicable standards and laws for Riverside Assisted Living at Patriots Colony.
Findings
The inspection found multiple areas of non-compliance including failure to obtain required written approvals for residents with serious cognitive impairments, incomplete resident records such as missing tuberculosis risk assessments, sex offender screenings, personal and social information, and resident agreements. Deficiencies were also noted in individualized service plans, medication availability, and emergency practice exercises.
Deficiencies (10)
| Description |
|---|
| Failed to ensure written approval prior to placing a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to document determination and justification for placement of resident in special care unit. |
| Resident records lacked timely tuberculosis risk assessments within 30 days preceding admission. |
| Failed to ascertain whether resident is a registered sex offender prior to admission. |
| Resident personal and social information was incomplete or not kept current. |
| Resident agreement/acknowledgement documents were missing or unsigned at admission. |
| Failed to provide and document orientation for new residents and legal representatives upon admission. |
| Individualized service plans did not include all assessed needs or updates for significant changes in condition. |
| Medications ordered for PRN administration were not available, properly labeled, or properly stored. |
| Staff on all shifts did not participate in emergency procedure practice exercises. |
Report Facts
Inspection dates: 3
Census: 64
Corrective action completion date: May 31, 2023
Audit frequency: 3
Audit frequency: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
| Darunda Flint | Inspector | Current inspector conducting the inspection |
| Staff #1 | Staff interviewed acknowledging deficiencies in resident records and procedures | |
| Staff #2 | Staff involved in medication pass observation acknowledging medication deficiencies | |
| Staff #8 | Staff acknowledging lack of emergency practice exercises on third shift |
Inspection Report
Renewal
Census: 63
Deficiencies: 6
Apr 5, 2022
Visit Reason
An unannounced renewal inspection was conducted on April 5 and 6, 2022 by two inspectors from the Peninsula Licensing Office to assess compliance with assisted living facility regulations.
Findings
The inspection identified multiple deficiencies including failure to secure harmful materials from residents, incomplete psychotropic medication treatment plans, missing or outdated personal and social information in resident records, incomplete individualized service plans, expired medication on the medication cart, and use of medical restraints without proper physician orders or legal consent.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure harmful ordinary materials or objects were inaccessible to residents except under staff supervision. |
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs for four of seven residents due to incomplete psychotropic medication treatment plans. |
| Facility failed to obtain and keep current required personal and social information for five of seven residents. |
| Facility failed to ensure individualized service plans included all assessed needs for two of seven residents. |
| Facility failed to monitor the medication cart to prevent use of outdated, damaged, or contaminated medications; expired Epipen found on cart. |
| Facility failed to ensure medical restraints were used only according to physician's written order and written consent of resident or legal representative. |
Report Facts
Facility census: 63
Residents with incomplete psychotropic medication treatment plans: 4
Residents with missing or outdated personal and social information: 5
Residents with incomplete individualized service plans: 2
Inspection Report
Monitoring
Census: 50
Deficiencies: 2
May 21, 2021
Visit Reason
A monitoring inspection was initiated on May 21, 2021, conducted remotely due to the state of emergency health pandemic declared by the Governor of Virginia. The inspection involved review of staff and resident records, healthcare oversight, nutrition reports, staff schedules, and emergency preparedness.
Findings
The inspection found non-compliance with applicable standards, including incomplete uniformed assessment instruments for one resident and lack of a valid physician's order for a dietary supplement (Boost) for the same resident. Corrective actions were planned and documented.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the uniformed assessment instrument (UAI) for one of three residents was completed as required, missing name, signature, and date of the individual who completed and reviewed the assessment. |
| The facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid order from a physician or other prescriber, specifically no physician's order was found for the resident receiving Boost supplement. |
Report Facts
Inspection dates: 4
Census: 50
Audit frequency: 5
Audit duration: 4
Inspection Report
Monitoring
Census: 57
Deficiencies: 1
Sep 29, 2020
Visit Reason
A monitoring inspection was initiated due to the need for oversight during a state of emergency health pandemic declared by the Governor of Virginia. The inspection was conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance related to individualized service plans (ISP) not containing all assessed needs for three of four resident records reviewed. Specific deficiencies included missing documentation of assessed needs such as feeding assistance, mobility help, diet restrictions, toileting, and instrumental activities of daily living.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure individualized service plan (ISP) contained all assessed needs for three of four resident records, including feeding, mobility, diet restrictions, toileting, and instrumental activities of daily living. |
Report Facts
Inspection dates: 5
Resident records reviewed: 4
Staff records reviewed: 4
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