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: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint 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. A complaint was received by VDSS Division of Licensing on 1/9/2024 regarding allegations in the area(s) of: Resident Care and Related Services 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the (allegation(s)/self-report) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-C
Complaint related:	No
Description:	Based on records reviewed, the facility failed to ensure medication be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. A review of the Medication Admin Audit Report for May 1, 2024 through May 21, 2024, for Resident #1, documented the resident received 30 doses of medication later than the standard dosing schedule. 2. A review of the Medication Admin Audit Report for May 1, 2024 through May 21, 2024, for Resident #2, documented the resident received over 90 doses of medication later than the standard dosing schedule.
Plan of Correction:	Measures to prevent non-compliance from occurring again: On the date of the inspection, LPNs and RMAs were provided with immediate in-service training covering proper medication administration, including ensuring all medications are administered no earlier than one hour before and no later than one hour after the dosing schedule, except for those drugs that are ordered for specific times. 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. Medication Administration Audit Report pulled via EMR PCC 3-5x weekly by clinical leadership team to identify late administration of medications. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services and/or designee.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of facility records, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The Medication Admin Audit Report for Resident #3 lacked documentation that prescribed medication was administered on the following days and times: 6/5/2023 9am 6/19/2023 5pm 6/24/2023 9am 7/8/2023 3pm, 6pm, 8pm 8/1/2023 3pm, 6pm 8/14/2023 3pm, 6pm, 8pm 8/19/2024 6pm, 8pm 8/28/2023 3pm, 6pm, 8pm 8/31/2023 3pm, 6pm 9/2/2023 3pm, 6pm, 8pm 10/8/2023 7am, 9am, 10 am 10/8/2023 7am, 9am, 10am 10/18/2023 3pm, 6pm, 8pm 10/21/2023 7am, 8am, 9am, 10am, 3pm, 6pm, 8pm 11/9/2023 12 am 11/11/2023 6pm, 9pm 11/12/2023 6pm, 9pm 11/15/2023 6pm, 9pm 2. The Progress Notes for Resident #3 documented a conversation between the resident and a staff member. The Progress Note states, ?Resident stated that staff suppose to administer her medication and that not being done?. 3. Resident #3?s Progress Notes do not document medications being held by the physician on the above days and times.
Plan of Correction:	Measures to prevent non-compliance from occurring again: LPNs and RMAs were provided with an immediate in-service training on the date of the inspection covering proper medication administration to include ensuring all medications are administered per MD orders unless a hold order or discontinue order is received by the MD. Staff will document resident refusals when attempts to administer medications per MD orders are unsuccessful in the progress notes and inform the MD. Medication Pass Observations are completed on a weekly basis at random to identify and ensure compliance with the standards as well as 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. Medication Administration Audit Report pulled via EMR PCC 3-5x weekly by clinical leadership team to identify late administration of medications. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services and/or designee.