VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Hidenwood Retirement Community
50 Wellesley Drive
Newport news, VA 23606
(757) 930-1075

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: May 21, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

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: 5/21/2024 9:10 am- 5:30 pm 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: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 4 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on the on-site record review and staff interview the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. (Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training). Evidence: 1. The record for Staff #3, a registered medication aide, did not include documentation of 12 hours of annual training.
Plan of Correction:	Measures to prevent non-compliance from occurring again: ? Business Office & HR Manager will review all team member monthly training hours due, overdue, and completed weekly, send a report to the Executive Director and department leaders, post a copy on the team member board and ensure follow up with team members occurs to schedule time in the community to complete required monthly training hours. ? Business Office & HR Manager will review all current team member training hours for compliance with the standard by 7/31/24. Team Members will be removed from the schedule until all training hours are completed. Persons responsible for implementation and/or monitoring preventative measures: ? Executive Director and Business Office & HR Manager
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge. Evidence: On the date of the inspection 5/21/2024, Manager on Duty posting was not up to date as the posting listed individuals who were not in the building at the time the inspector started the inspection.
Plan of Correction:	Measures to prevent non-compliance from occurring again: Person in Charge Sign (Manager on Duty Signage) is at the Concierge Desk, on the wall. - Concierge coming in at 0800AM will call Nurse?s Station to see who is charge nurse for that time and will make sure the MOD sign has that person?s name in the MOD slot. -The Executive Director will notify the Concierge when they have arrived so the Concierge can change the MOD name to the ED?s name. --If the Executive Director is out of the office for the day, then the Director of Clinical Services will notify the Concierge of their arrival so the Director of Clinical Services name will be in the MOD slot. -At the end of the business day, the Person in Charge will notify the Concierge that they are leaving the building. The Concierge will then change the MOD name to the current Charge Nurse on duty. -At the change of the Charge Nurse?s shift, the new Charge Nurse will notify the Concierge that they are in the building and the Concierge will then change MOD name to the present Charge Nurse. -At the end of the Concierge?s shift at night, the Concierge will check in with the Charge Nurse to make sure the Person on Duty is current and correct. -If the Person in Charge changes after the Concierge has left, the Person in Charge will update their name on the posting. Persons responsible for implementation and/or monitoring preventative measures: -Executive Director, Concierge, Charge Nurses and/or designee
Standard #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: Resident # 5 had an admission date of 2/21/2024 and the Sex Offender Screening was conducted on 4/16/2024.
Plan of Correction:	Measures to prevent non-compliance from occurring again: ? Prior to the contract signing, all residents will have a Sex Offender Registry Search completed and in their business file by the Director of Community Relations. ? Executive Director will audit and verify the Sex Offender Registry Search was completed and in the business file prior to contract signing. ? Business Office Manager will audit and verify the Sex Offender Registry Search was completed in the business file once the business file is received from the Executive Director. ? A full audit of all current residents will occur to ensure there is a current sex offender registry search completed, printed and within their business file. Persons responsible for implementation and/or monitoring preventative measures: ? Executive Director, Director of Community Relations, Business Office Manager
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified. Evidence: 1. Resident # 4?s ISP dated 2/2/2023 stated the resident needed physical assistance with dressing. The resident?s UAI dated 1/16/2024 stated the resident required mechanical and human assistance with dressing. 2. Resident #4?s ISP dated 2/2/2023 stated the resident needed supervision when toileting. The resident?s UAI dated 1/16/2024 stated the resident required mechanical and supervision when toileting. 3. Resident #4?s ISP dated 2/2/2023 stated the resident needed mechanical and human assistance with stairclimbing. The resident?s UAI dated 1/16/2024 stated the resident does not perform stairclimbing. 4. Resident #6?s ISP dated 5/6/2024 stated the resident does not walk due to general weakness. The residents UAI dated 9/27/2023 stated the resident required mechanical assistance only when walking. 5. Resident #6 has a Do Not Resuscitate Order dated 5/13/2024 and the ISP dated 5/6/2024 stated the resident was a Full Code. 6. Resident #6 is receiving Hospice services which are not reflected on the ISP dated 5/6/2024.
Plan of Correction:	Measures to prevent non-compliance from occurring again: ? Director of Clinical Services, Assistant Director of Clinical Services and/or designee will ensure that each residents ISP contains description of all identified needs and services through utilizing the electronic health record assessments, auditing UAIs to ISPs to ensure specific descriptions of assistance needed is listed and updating ISPs within 24-48 hours of any significant status change. ? Director of Clinical Services, Assistant Director of Clinical Services, and/or designee will audit (10) resident ISPs per week for compliance and update as necessary. Persons responsible for implementation and/or monitoring preventative measures: ? Director of Clinical Services, Assistant Director of Clinical Services, or designee
Standard #:	22VAC40-73-550-G
Description:	Based on the review of facility records and staff interviews conducted the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence: 1. The file presented to the Licensing Inspector at the time of inspection for Resident #1 contained a review of resident?s rights dated 11/30/2022.
Plan of Correction:	Measures to prevent non-compliance from occurring again: ? Business Office Manager will ensure that all residents and/or legal representatives receive a copy of the resident rights and responsibilities annually based on admission month for review and signature. ? Business Office Manager will ensure that three attempts to obtain the resident and/or legal representative signature annually is documented within the resident record. ? Business Office Manager will complete a full resident file audit to ensure all current residents have a signed resident rights and responsibilities acknowledgement within their file. ? Business Office Manager will audit monthly to ensure compliance based on the resident?s admission month.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: 1. A review of the Controlled Substance Verification/Shift Count Sheet for all of the medication carts in both the memory care and assisted living units documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff. 2. Staff members #3 and #4 acknowledged the forms did not document narcotic medication counts were conducted during the change of each shift.
Plan of Correction:	? Staff education sessions will be held to educate the LPN/RMA staff on the Medication Management Policies, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes shift by documenting the complete of the shift-to-shift narcotic count sheet at the end/start of every shift. ? Medication Pass Observations are completed weekly at random to identify and ensure compliance with the standards and our Medication Administration Policy. ? Medication Pass Observations are completed by the Regional Director of Clinical Services during healthcare oversight visits and quarterly quality assurance audits. ? Quarterly 3rd Party Medication Administration Observation to occur through Omnicare. Persons responsible for implementation and/or monitoring preventative measures: ? Director of Clinical Services, Assistant Director of Clinical Services, Charge Nurses, Registered Medication Aides
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interviewed, the facility failed to ensure medication was stored in a manner consistent with current standards of practice. Evidence: 1.During the on-site medication observation on 5/21/2024, the licensing inspector observed Melatonin, Loratadine 10ml, Tums, and Lotemax eyedrops on the dresser of Resident #8. 2. Staff #4 acknowledged the resident is not able to self-medicate and Staff #3 acknowledged the medications were present.
Plan of Correction:	Measures to prevent non-compliance from occurring again: -Staff education sessions will be held to educate the LPN/RMA staff on Medication Storage. -The Omnicare General Medication Storage Guideline and audit form will be used to conduct weekly routine checks to ensure appropriate medication storage practices are being followed. -Weekly rounds on resident apartments and community for continuity of proper medication storage. Persons responsible for implementation and/or monitoring preventative measures: -Director of Clinical Services, Assistant Director of Clinical Services, Charge Nurses, Registered Medication Aides