VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hidden Springs Senior Living
973 Buck Mountain Road
Bentonville, VA 22610
(540) 636-2008

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 15, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Technical Assistance: 1) Ensure you are using model form of current disclosure statement. Copy provided. 2) Ensure you are using model form for resident physical examination. Copy provided. 3) Ensure PPD form includes all required information. Copy provided.

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 renewal inspection was initiated on 07/15/20 and concluded on 07/21/20. The administrator was contacted to initiate the inspection. The administrator reported the current census as 66. The inspector emailed the administrator and director of nursing a list of items to completed the inspection. The inspector reviewed four resident records and four staff records, criminal history reports, medication administration records and staff schedule submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based upon review of residents' records, the facility failed to ensure the Individualized Service Plan (ISP) reflects the identified needs as per the Uniform Assessment Instrument (UAI) . EVIDENCE: 1) The UAI for resident A indicates disorientation to time and place. The ISP indicates disorientation to time, person and place. a. The ISP indicates to re-direct resident when abusive, aggressive and disruptive behavior occurs. There are no interventions indicated on the ISP for re-direction. b. The UAI indicates mechanical and physical assistance is needed with toileting. This is not identified on the ISP. c. Inability to use the call bell system is not on the ISP. Resident A has a serious cognitive impairment. 2) The ISP for resident B does not identify services provided by hospice. a. The UAI indicates abusive, disruptive and aggressive behavior. The ISP indicates resident is resistant to care at times and to re-direct. There are no interventions indicated on the ISP for re-direction. b. The MAR for resident B indicates use of a Hoyer lift. This is not indicated on the ISP. 3) The UAI for resident C indicates physical and mechanical assistance is needed with toileting. This is not indicated on the ISP. a. Resident has a DNR dated 07/10/20. The ISP indicates resident is a full code. 4) The UAI for resident D indicates physical and mechanical assistance is needed with toileting. This is not indicated on the ISP.
Plan of Correction:	1) UAI for res A indicates disorientation to time and place. ISP indicates redirect resident when abusive or has disruptive behavior. UAI indicates mechanical and physical when toileting. Serious cognitive impairment with no ISP on inability to use call light. ISP does not reflect these deficits. ISP corrected for deficits listed above 8/6/2020 2) ISP for resident B does not identify services provided by Hospice. Corrected 8/6/2020. No intervention on ISP for disruptive or aggressive behavior. Corrected 8/6/2020 No ISP for use of hoyer lift. Corrected 8/6/2020 3) Resident C Physical and mechanical assist with toileting not on ISP. Corrected 8/6/2020 DNR not reflected on ISP. Corrected on 8/6/2020 4) Resident D indicates physical assistance is needed with toileting. This is not on ISP. Corrected on 8/6/2020 Plan of correction: 100% audit of all UAI and ISP is under process and will be completed by 8/31/2020 to ensure all areas on UAI are in ISP. All residents with severe cognitive impairment will be assessed by 8/31/202 for the ability to use call light and ISP will be updated. Audit of DNR and Full code was performed on 8/5/2020 to ensure ISP reflected correct information. All staff who update ISP have been educated on the need to review UAI with every update to ISP.
Standard #:	22VAC40-73-450-E
Description:	Based upon review of residents' records, the facility failed to ensure the signature of resident, legal representative and person who developed the plan is included on the ISP. a. The ISP for resident A did not contain a signature of the legal representative. b. The ISP for resident B did not contain a signature of the legal representative or person completing the plan. c. The ISP for resident C did not contain a signature of the legal representative.
Plan of Correction:	ISP has been resent to family, awaiting signature. 100% audit conducted on all CP for signatures. All signatures are in place except for 3 residents above and for 1 additional resident. Plan of correction: A list of all ISP will be tracked when ISP are sent to families. If in 1 week we do not receive back LPN,ADON,DON, Administrative assistant will follow up families to ensure we receive in a timely manner.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' records, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1) The Medication Administration Record (MAR) for resident A indicates 14 refusals for 8:00am and 8:00pm medications for the month of July. There is no documentation of physician notification. 2) Resident B has the following order: Check weight every day for weight monitoring.If patient gains greater than 5lbs in 24 hours, notify provider. a. The MAR indicates weight was not obtained on 07/09/20 and 07/10/20 due to "resident would not sit still for weight."; 07/11/20 and 19/12/20 "on isolation"; 07/14/20 and 07/17/20 due to "resident in bed" b. Documentation indicates resident was weighed on 07/13/20 c. There is no documentation of physician notification. 3) Resident B has the following order Potassium CL 10% (20MEQ/15ml)-Give 7.5ml (10MEQ) by mouth daily for Hypokalemia. a. Documentation in the MAR indicates medication was not administered on 7/04 "refused; 07/05/20 "waiting on Rx"; 07/14/20 "medication not in cart." b. There is no documentation of physician notification. 4) Resident B has the following order: TED HOSE Knee Hi-Apply to bilateral lower extremities every morning and remove every night. a. Documentation in the MAR indicates TED hose were not applied on 07/07/20 "unable to find" "not located in am" and on 07/13/20 "resident's TEDs were washed and still wet." 5) Resident D has the following order: "Lisinopril 10mg-Take one tablet by mouth every day for hypertension. Hold for systolic blood pressure less than or equal to 110 or diastolic blood pressure is less than 70. a. Documentation in the MAR indicates resident's blood pressure was 133/74 on 07/02/20 and medication was not administered. 6) Resident D has the following order: Carvedilol 25mg-Take one tablet by mouth two times a day with food. Hold for systolic blood pressure less than or equal to 100 and diastolic blood pressure less than or equal to 50. a. Documentation in the MAR indicates medication was not administered on 07/04/20 and 07/05/20 due to being "outside parameters". There is no blood pressure documented on the MAR. 7) Resident D has the following order: Pro Air inhaler-Inhale two puffs into the lungs four times a day for shortness of breath. a. Documentation in the MAR indicates medication was not available for administration on 07/18/20 at 12:00pm, 4:00pm and 8:00pm. 8) Resident D has the following order: IPRAT-ALBUT 0.5-3 (2.5) MG/3ml: Inhale 1 vial via nebulizer every 4 hours as needed for shortness of breath. Call hospice is symptoms persist past 4 hours. a. Documentation in the MAR indicates medication was administered on 07/11/20 at 5:57pm. Documentation of results at 6:32 indicates "med is not effective, LPN notified." b. There is no documentation of follow-up. 9) Resident D has an order to monitor BMs every shift. a. There is no documentation of staff initials on the MAR to indicate this was completed.
Plan of Correction:	1) Resident A refusal of medication without documentation of physician notification. Resident A has been seen by NP on 8/4/2020 and was notified of residents refusals 2) Resident B order to weigh every day for weight monitoring was not done from 7/9-7/24 Verbal order from Physician to hold daily weights for 2 weeks was received and verbalized to staff but no hold was placed in the MAR which led to inconsistencies. All holds have been corrected in MAR 8/4/2020. 3) Resident B Potassium was held due to refusal on 7/4, 7/14/2020 medication not in cart. Physician notified 8/4/2020. Med cart review of all meds to ensure reordering done 8/5/2020. 4) Ted hose for resident B not applied on 7/7/2020 and 7/13/2020. Additional ted hose ordered 8/5/2020 to ensure resident has available as per physicians orders 5) Resident D Lisinopril 10 mg was not given per physicians orders when within parameters. 1:1 education provided to staff members involved 8/6/2020. 6) Resident D Carvedilol not given per physicians orders when within parameters. 1:1 education provided to staff member involved 8/6/2020. 7) Resident D Pro Air not available on 7/18/2020 and was not given. 1:1 education to staff member on notification to LPN when med not available 8/6/2020 8) Resident D Iprat Albuterol was administered and not effective. Physicians order indicates if not effective notify BRH. LPN was notified and no follow up on whether Blue ridge hospice was notified. Blue Ridge Hospice notified on 8/7/2020. Med review and assessment done.LPN and staff involved in incident educated 8/5/2020. 9) Resident D has order to monitor BMs every shift. No initials in MAR to indicate this was done. Residents MAR corrected on 8/7/2020 Plan of correction to correct deficient practice: Staff education done for all staff starting 8/5/2020. All staff have been educated on the need to notify LPN of resident refusals of medication. LPN?s have been educated on the need to document physician notification. LPN?s educated on the need to update MAR when order to hold a treatment is received. Staff educated on need to reorder medications in a timely manner and when not available notify LPN in charge. Staff educated on medications with parameters that when medication is held to ensure vitals are documented in the MAR and to double check order to ensure correct action is being taken. LPN, ADON, DON will monitor medication dashboard on a daily basis to view medications that were missed, refused or held to ensure proper procedures are being followed. A tracking sheet will be utilized for all follow ups that are needed and will be followed up by nursing.
Standard #:	22VAC40-90-40-B
Description:	Based upon review of staff records, the facility failed to ensure a criminal history report was obtained on or prior to the 30th day of employment. EVIDENCE: 1) The file for staff M hired on 09/26/19 does not contain a criminal history report. 2) The file for staff Q hired on 01/24/20 does not contain a criminal history report.
Plan of Correction:	All requests have been made to obtain criminal history report for above staff members. Plan of correction. A tracking form has been updated on 8/6/2020 to reflect 2 columns, which will indicate when background check was requested and when received. This tracking form will be reviewed weekly by business office manager. If background checks are not received back within 30 days, Business office manger will reach out to the Virginia State Police to inquire about the background checks.