VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Riverside Assisted Living at Warwick Forest
860 Denbigh Blvd.
Newport news, VA 23602
(757) 886-2000

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: March 5, 2019 , March 6, 2019 and March 8, 2019

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced renewal inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 03-05-2019 from 9:06 AM to 4:13 PM and on 03-08-2019 from 10:15 AM to 12:48 PM; and by two Licensing Inspectors from the Eastern Regional Office on 03-06-2019 from 10:24 AM to 4:32 PM. There were 125 residents in care at the time of the inspection. A tour of the facility was conducted, water temperatures were sampled, an activity and lunch were observed, and the emergency food and water supply was reviewed. A medication pass observation was completed with 2 staff members (one on the S.C.U and one on the AL unit).10 resident records and 5 staff records were reviewed. The Criminal Background Checks and Sworn Disclosures were reviewed for all new hires since the previous inspection in May 2018. Interviews were conducted with staff and residents. LI reviewed the following: First Aid kits, menus, activity calendars, emergency preparedness exercises, fire drills, resident council, and staff schedules. The following was discussed with the Administrator during the inspection: Resident Rights as it relates to the Code of Virginia, the facility's Certificate of Occupancy, MAR's, maintenance work orders, private caregivers, ISP's, and the Health care oversight. The facility received violations "under" Personnel, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, Emergency Preparedness, and Additional Requirements for Facilities that Care for Residents with Serious Cognitive Impairments. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the -Plan of Correction- for each violation cited on the violation notice and return it to me within 10 calendar days from today, on 04-27-2019. You will need to specify how the violation will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measure.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review and interview, the facility failed to ensure that prior to admission to a safe, secure environment, the resident should be assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. During resident #8?s record review on 03-06-2019 with staff #1, staff #2 and staff #3, the resident was admitted to the "Evergreen" Special Care Unit (S.C.U) from the assisted living unit on 02-12-2019. The Licensing Inspector, with staff #1, staff #2 and staff #3 could not locate resident #8?s assessment of serious cognitive impairment form which is completed by a physician prior to admission into the S.C.U. 2. During interview, staff #3 and staff#2 acknowledged that resident #8 was admitted to the S.C.U on 02-12-2019, and indicated that the assessment for serious cognitive impairement had not been completed by a physician prior to the resident's admission into the S.C.U.
Plan of Correction:	On the day of the survey, an immediate correction made. The guardian/POA informed and the doctor order requested from the hospice agency. The serious cognitive impairment assessment was completed for resident #8. All memory care unit admission records will be reviewed by the unit manager/designee to ensure all the admission records and contact information are current. All findings will be corrected and reported to the QA Committee for continued improvement and analysis. Education was provided to nursing staff and the hospice agency by the Administrator/designee regarding the resident admission and discharge, requirements and communication. The process will be reviewed by the Administrator/designee monthly for 3 months. All the findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-1100-A
Description:	Based on record review and interview, the facility failed to ensure that 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 shall obtain the written approval of one of the following persons, in the following order of priority: the resident, a guardian or other legal representative, a relative who is willing and able to take responsibility to act as the resident's representative, or a physician if all others are unavailable. Evidence: 1. During resident #8?s record review on 03-06-2019 with staff #1, staff #2, and staff #3, the resident was admitted from the assisted living unit to the "Evergreen" Special Care Unit (S.C.U) on 02-12-2019. The Licensing Inspector, staff #1, staff #2, and staff #3 were unable to locate written approval by the resident or the resident's guardian, legal representative, relative, or physician for resident #8?s placement into the S.C.U. 2. During interview with staff#1, staff #2, and staff #3 acknowledged resident #8 was admitted to the S.C.U on 02-12-2019 after obtaining verbal approval from the resident's family; however, the facility did not have a written approval for placement by the family prior to the resident's admission into the S.C.U.
Plan of Correction:	On the day of the survey, an immediate correction made. Resident?s guardian contacted and obtained the signed approval from the physician and the guardian. Education regarding residents? admission, discharge, and transfer to the Evergreen special care unit provided to the staff members. Nurse managers/designee will ensure the appropriate communication and documentation of admission, discharge and transfer are in place. Admission, discharge, and transfer process will be reviewed by the Administrator by reviewing 2 admission to the secured unit per month. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review and interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the 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. During resident #8?s record review on 03-06-2019 with staff #1, staff #2, and staff #3, the resident was admitted to the "Evergreen" Special Care Unit (S.C.U) from the assisted living unit on 02-12-2019. The Licensing Inspector, staff #1, staff #2, and staff #3 were unable to locate a written justification by the administrator or designee to justify resident #8?s placement into the SC.U. 2. During interview on 03-06-2019, staff #3, staff #2, and staff#1 confirmed the facility did not complete a determination and justification prior to placing resident #8 in the S.C.U.
Plan of Correction:	An immediate record audit performed on the day of the survey for Resident #8. Written justification was completed by the Administrator/designee. Education regarding residents? admission, discharge, and transfer to the Evergreen special care unit provided. Nurse managers/designee will ensure the appropriate justification and documentation on admission, discharge and transfer are in place. Admission, discharge, and transfer process will be reviewed by the Administrator by reviewing 2 admission to the secured unit per month. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Evidence: 1. On 03-05-2019, during staff #6's record review with staff #5, staff #6 was hired on 09-10-2018 as a Registered Medication Aide. The Licensing Inspector and staff #5 were unable to locate a First Aid certification on file for staff #6. 2. During interview on 03-06-2019, staff #3 confimed the facility did not have a First Aid certificate on file for staff #6.
Plan of Correction:	On the day of the survey, an immediate correction made. An immediate First Aid class provided to staff #6. A 100% audit of the training and certification record performed by the Administrator/designee, upcoming renewals are identified, and a first aid and CPR training programs updated and posted throughout the facility. Unit managers and the facility educator will ensure the staff licensure and certification records are current. The process will be reviewed by the Administrator/designee for 3 months by reviewing 5 staff records monthly. All the findings will be communicated to the staff members and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and interview, the facility failed to ensure in accordance with ? 63.2-1805 D of the Code of Virginia, the facility did not retain individuals whose physical care needs cannot be met in the specific assisted living facility as determined by the facility. Evidence: 1. During resident #4?s record review on 03-06-2019, the current Uniform Assessment Instrument (UAI) dated 10-11-2019 was checked ?yes? indicating the resident has a prohibitive condition due to ?Dependence on others to perform all activities of daily living (ADL).? The UAI also revealed the resident is dependent on staff for bathing, transferring, and wheeling; and does not perform toileting, walking, or stairclimbing. In addition, the Individualized Service Plan (ISP) dated 02-22-2019 revealed the resident needs a hoyer lift and max 2 person assist with transferring, and needs assistance from staff/private sitter to push resident in the wheelchair. 2. On 03-06-2019, during interview, staff #11 stated ?resident #4 has a prohibitive condition due to needing assistance with all ADL care.? 3. Upon further review of resident #4?s record, a ?Private Duty Sitter Authorization? form dated 03-01-2019 revealed the resident would have a private duty caregiver ?while awake? and ?during the day.? 4. On 03-08-2019, during interview staff #2 stated "resident #4 has a private duty caregiver in place for 16 hours each day; however the resident is only safe with 1 on 1 care and needs a 24 hour sitter."
Plan of Correction:	Resident #4 was already in the process of admitting to a nursing home facility; he transferred as of 4/16/2019. While pending transfer, resident continued to receive care by facility staff, 1:1 sitters and was on 30 minute checks. A %100 audit of the UAIs will be conducted by the nurse manager/designee to ensure no residents present with a prohibiting condition. All findings will be corrected and reported to the QA Committee for continued improvement and analysis. In service training, related to the facility specific care services and prohibitive conditions, provided to nursing staff by Educator/designee. The process will be reviewed by the Administrator /designee monthly for three months with an audit of 1 residents with annual individual service plan evaluation. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-440-D
Description:	Based on record review and interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed as required by 22VAC30-110. Evidence: 1. During resident record review on 03-05-2019 and 03-06-2019, resident #2?s current UAI dated 02-25-2019 and resident #8?s current UAI dated 01-11-2019 was not signed by the Administrator or designee. 2. During resident #3?s record review on 03-06-2019, the current UAI dated 01-16-2019 revealed the resident only needs assistance with instrumental activities of daily living (IADLs) and no activities of daily living; however, the resident was assessed as being at assisted living level of care (requiring assistance in 2 or more activities of daily living) and not as residential living level of care (requiring assistance in only 1 activity of daily living). 3. During interview on 03-06-2019, staff #1 acknowledged the missing signatures on resident # 2 and resident #8?s UAI?s, and acknowledged that resident #3 only needs assistance with IADLs and is at the residential level of care.
Plan of Correction:	UAI of residents #2 and #8 reviewed and signed by the administrator. Resident #3?s UAI was updated by the nurse manager to reflect residential living level of care. A 100% audit of UAIs will be completed by the Administrator/designee to ensure the appropriate level of care in documented based on the responses on the UAI. Nurse Managers/designee will ensure all the UAIs are turned into the Administrator /designee for signature prior to being filed in the resident?s record. Nurse managers will be re-educated by the Administrator/designee on the difference between the residential level on the UAI and the residential fee at the facility. The process will be reviewed by the Administrator/designee monthly for three months with an audit of 5 residents with an annual assessment or significant changes. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-450-D
Description:	Based on record review and interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the Individualized Service Plan (ISP). Evidence: 1. During resident #8?s record review on 03-06-2019, the record revealed the resident is on hospice. Review of the hospice notes revealed the resident received a social worker visit on 02-13-2019, 02-20-2019, and 03-01-2019; a health aide visit on 02-20-2019, 02-25-2019, and 03-04-2019; and a Registered Nurse visit on 02-13-2019, 02-20-2019, and 02-24-2019. Further review of the record revealed that resident?s current ISP dated 03-08-2018 identified hospice services on 11-09-2018, but did not indicate a description of the services provided by hospice to include the social worker, health aide, and RN. 2. During interview, staff #2 and staff #1 acknowledged the services being provided by hospice were not reflected on resident #8?s ISP dated 03-08-2018.
Plan of Correction:	Individualized Service Plan of Resident #8 reviewed and updated on the day of the inspection by the nurse manager to reflect hospice services. An audit of residents receiving hospice services will be conducted by the nurse managers/designee to ensure such services are documented on the resident?s ISP. All findings will be corrected and reported to the QA Committee for continued improvement and analysis. Education related to Individualized Service Plans (ISP) and the importance of describing the third party care services (hospice, home health, and private duty sitters) provided to the unit managers and nurses by the Administrator/designee. The process will be reviewed by the Administrator/designee monthly for three months with an audit of 5 residents with an annual assessment and ISP updates. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-450-E
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was signed and dated by the resident or the legal representative. Evidence: 1. During resident record review on 03-05-2019 and 03-06-2019, the following ISP?s were not signed or dated by the resident of the resident?s legal representative: resident #1?s current ISP dated 02-09-2019; resident #2?s current ISP dated 02-25-2019; resident #8?s current ISP dated 03-08-2018 and updated ISP dated 01-10-2019; resident #6?s current ISP dated 10-08-2019; and resident #5?s updated ISP on 01-28-2019. The Licensing Inspector did not observe documentation of attempts made to obtain a signature from the resident or the legal representative regarding the aforementioned ISP?s. 2. During interview on 03-06-2019, staff #2 and staff #1 acknowledged the missing signatures on the aforementioned ISP?s for residents #1, #2, #8, #6, and #5.
Plan of Correction:	The ISPs for resident #1, #2, #8, #6 and #5 were reviewed by the Administrator/designee and reviewed with and signed by the resident/representative. Nurse managers will ensure all the current and previously updated Individualized Service Plans (ISP)s are approved by the residents, family members, and the Administrator /designee. All findings will be corrected and reported to the QA Committee for continued improvement and analysis. The nurse managers will be educated by the Administrator/designee on the required signatures of the ISP during annual reviews and significant changes. The process will be reviewed by the Administrator/designee monthly for three months with an audit of 5 residents with an annual assessment and ISP updates. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-490-A
Description:	Based on record review and interview, the facility failed to ensure when residents meet the criteria for assisted living care, the licensed health care professional, practicing within the scope of his profession provide health care oversight at least every three months. Evidence: 1. During review of the facility?s health care oversight, the Licensing Inspector (LI) observed the last health care oversight was conducted on 06-28-2018 for the quarter of 03-01-2018 through 06-30-2018. Staff #3 and staff #2 were unable to provide LI with an additional healthcare oversight. 2. During interview, staff #3 and staff #2 acknowledged the facility?s last healthcare oversight provided by a licensed healthcare professional was on 06-28-2018.
Plan of Correction:	The required health care oversight will be completed. Facility will hire/designate a new staff member as the health care oversight. The Administrator was educated on the requirement for health care oversight by the Executive Director/designee. The process will be reviewed by the Administrator/designee every 3 months with an audit to ensure the biannual healthcare oversight is in progress or complete. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-550-G
Description:	Based on record review and interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each staff person. Evidence of this review should be the staff person's written acknowledgment of having been so informed, which should include the date of the review and should be filed in the staff person's record. Evidence: 1. During staff record review on 03-06-2019 and 03-07-2019 with staff #5 and staff #9, staff #7 (hired on 12-11-2006) and staff #8 (hired on 03-01-2010), did not have documentation on file to verify the annual rights and responsibilities of residents in assisted living facilities were reviewed. In addition, the Licensing Inspector (LI) was not provided with a previous resident rights review for staff #7 or staff #8. 2. During the inspection, staff #3 provided the LI with a copy of an exam regarding ?Patient/Resident Rights and Reporting Patient Events;? however, the exam material did not include all of the rights and responsibilities contained in ? 63.2-1808 of the Code of Virginia. 3. During interview on 03-08-2019, staff #2 indicated staff #8 and staff #7 missed the resident rights training and confirmed both staff did not have documentation on file to verify the annual rights and responsibilities of residents in assisted living facilities were reviewed.
Plan of Correction:	Staff #5, #9, #7 and #8 received resident right education. Education was provided to the staff regarding the importance of annual review of the residents? rights by the Administrator. Facility educator/designee will ensure the resident?s right will be reviewed and signed by the staff members and the residents annually. Records will be maintained by the nursing staff, human resources manager, and the facility educator. The process will be reviewed by the Administrator/designee monthly for 3 months with an audit of 3 resident and 3 staff members who have annual updates. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, record review, and interview, the facility failed to implement methods to prevent the use of outdated medications. Evidence: 1. On 03-05-2019, during a spot check of the medication cart (Keswick Cart B-Windsor Unit) with staff #4 the Licensing Inspector (LI) observed the following expired medications: 1 bottle of Carbidopa-Levo ER 25-100 Tabs with a ?discard? date of 10-18-2018, 1 bottle of Nitrostat .4mg Tabs with an ?expiration? date of 11-2018, and 1 bottle of Simvastatin 80mg Tabs with an ?expiration? date of 01-31-2019. 2. During the inspection, staff #1 provided LI with a copy of the facility?s ?Medication Storage? policy dated 06-21-2017, which states: ?Outdated, contaminated, or deteriorated medications ? are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed.? 3. During interview on 03-05-2019, staff #4 and staff #1 acknowledged the aforementioned medications located on the medication cart (Keswick Cart B-Windsor Unit) were expired.
Plan of Correction:	Medications identified in the report were immediately discarded by the nurse manager/designee. An audit of all medication carts performed by the unit nurse managers. All expired medication discarded. A letter regarding the medication administration policy of the facility sent to the family members, the physicians. Nurse manager/designee will ensure all the medication carts screened and expired medications are discarded monthly. Medication Administration Records (MAR) and Physician Order Statement (POS) are updated. The process will be reviewed by the Administrator/designee monthly for 3 months with an audit of 5 medication carts and 3 residents? apartment will be screened. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, record review, and interview, the facility failed to ensure the resident was permitted to keep their own medication in an out-of-sight place in their room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medications. Evidence: 1. On 03-05-2019, during the medication pass observation with staff 4, the Licensing Inspector (LI) observed 1 bottle of gas X located on a shelf in resident #7's room, 1 bottle of nasal spray located on resident #7's bathroom shelf, and 1 tube of nystatin powder located on the sink counter in resident #7's bathroom. 2. During resident #7?s record review on 03-05-2019, the current UAI dated 12-28-2018 indicated medications are to be administered/monitored by professional nursing staff. 3. Upon further review of resident #7?s record, the resident had a physician?s order dated 02-26-2019 for Gas X and an order dated 01-03-2019 for the nasal spray and nystatin powder; however, the orders did not indicate that the medications could be self-administered by the resident. 4. Staff #1 provided LI with a copy of the facility?s ?Medication Management Plan? dated 12-05-2005 which stated ?Residents who wish to self-administer medications must be assessed by the Nurse Leader to be competent in administrating their medication and have a written physician?s order, stating that they may self administer..? 4. During interview, staff #4 acknowledged the aforementioned medications in resident #7?s room and stated the resident did not have a physician?s order or assessment on file to self-administer medications.
Plan of Correction:	The identified over the counter medication found in Resident #7?s room was secured. All residents? apartments were screened by nurse manager/designee for unapproved medications. Findings were corrected and reported to the QA Committee for continued improvement and analysis. Information regarding approved storage of medication was provided to the residents, family members, physicians, and the nursing staff by the Administrator/designee. The nurse manager/designee will ensure an appropriate diagnosis and medication orders are in place for any new medication, update the Medication Administration Records (MAR), and Treatment Administration Records (TAR). The process will be reviewed by the Administrator/designee by screening 3 residents? apartments monthly for 3 months. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the date and time given and initials of direct care staff administering the medication. Evidence: 1. During review of resident #8?s record review on 03-06-2019, the February 2019 MAR did not include documentation to verify that the following medications were administered: a. Baza Protectant Cream (scheduled two times per day) during the 4:00 PM medication pass on 02-01-2019, 02-09-2019, 02-15-2019, 02-24-2019 and during the 8:00 AM medication pass on 02-13-2019, 02-14-2019, 02-23-2019. b. Chlorex oral rise (scheduled two times per day) during the 4:00 PM medication pass on 02-01-2019, 02-09-2019, 02-24-2019 and during the 8:00 AM medication pass on 02-13-2019 and 02-23-2019. c. Areds formula tab (scheduled two times per day) during the 8:00 PM medication pass on 02-09-2019 and 02-24-2019. d. Ensure (scheduled three times per day) during the 8:00 AM medication pass on 02-13-2019, 02-23-2019; also during the 8:00 PM medication pass on 02-09-2019, 2-17-19, and during the 2:00 PM medication pass on 02-24-2019. 2. On 03-06-2019, during interview, staff #1 and staff #2 acknowledged that the aforementioned dates were left blank on resident #8's February 2019 MAR.
Plan of Correction:	Resident #8?s MAR was reviewed by the nurse manager/designee. The resident?s physician was notified of the missed documentation of administration. A 100% audit will be completed of the current month of all residents? MAR for missed documentation. All findings will be reported to the QA Committee for continued improvement and analysis. Education regarding medication administration and record keeping provided to the nursing staff by the nurse managers The process will be reviewed by the Administrator/designee monthly for 3 months with an audit of 5 MARs. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
Standard #:	22VAC40-73-980-B
Description:	Based on observation and interview, the facility failed to ensure the first aid kit on the motor vehicle used to transport residents for a field trip included the required items. Evidence: 1. On 03-06-2019, staff #2 provided the first aid kit located on the facility?s bus to the Licensing Inspector (LI). During review of the first aid kit, LI observed the following items were missing: a disposable single use breathing barrier shield for rescue breathing or CPR, a blanket, plastic bags, a small flashlight with extra batteries, and a thermometer. 2. During interview on 03-06-2019, staff #2 confirmed the aforementioned required items were missing from the first aid kit located on the facility's bus.
Plan of Correction:	On the day of the survey, an immediate correction made. The items missing from the facility bus first aid kit were replaced. All the First Aid Kits screened and all the items replaced by the nurse manager/designee. Unit managers were re-educated by the Administrator/ designee on ensuring screening and updating of each units? first aid kit at least monthly. The process will be reviewed by the Administrator/designee monthly for 3 months with an audit of 5 first aid kit. All the findings will be communicated to the staff members and reported to the QA Committee for continued improvement and analysis.