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

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

Inspection Date: April 23, 2019 and April 24, 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
32.1 Reported by persons other than physicians
63.2 General Provisions.
63.2 Protection of adults and reporting.
22VAC40-90 Background Checks for Assisted Living Facilities
22VAC40-90 The Sworn Statement or Affirmation
22VAC40-90 The Criminal History Record Report
22VAC40-80 THE LICENSE.

Comments:
An unannounced renewal inspection with staff from Peninsula and Eastern Licensing offices was conducted on 4-23-19 (ar 8:06 am/dep 7:33 pm) and 4-24-19 (ar 9:50 am/dep 4:40 pm). The facility census on 4-23-19 was 107. The breakfast meal was observed on the assisted living and the special care unit with a variety of juice, meat, and cereals served as well as special request per resident. Dietary director reminded to post meal times for residents. Medication pass observation conducted, staff, family and resident interviews conducted, emergency food supplies observed, staff advised to remove dent can items. Staff and resident records were reviewed, including new hires since last inspection. The inspector discussed violations and concerns with facility staff and administrator throughout the two days of the inspection. The exit interview was conducted on both days of the inspection with the administrator and staff present. The medication management plan was discussed as there were concerns regarding the times of medication administration. Inspector suggested facility review it plan, particularly the facility's dosing schedule. ISP and therapy or other support services were discussed during the inspection. Areas of non-compliance are identified on the violation notice. Complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing inspector within 10 calendar days of receipt. Should you have any questions contact the licensing inspector at (757) 439-6815.

Violations:
Standard #: 22VAC40-73-320-B
Description: Based on record review and interview the facility failed to ensure a subsequent risk assessment for tuberculosis (tb) was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. While reviewing the resident records with staff #2 , the inspector found resident #4's last assessment was dated 3-23-18. There was no documentation file on the day of the inspection( 4-23-19) of an annual risk assessment for tuberculosis . 2. Staff #2 confirmed resident #4 had no documentation on file of an annual assessment for tuberculosis since 3-23-18.

Plan of Correction: Resident #4 TB screening completed.

All resident TB screening reviewed for completion.

TB screens will be reviewed during 30 day chart reviews. TB screens that are found due will be completed immediately.

Standard #: 22VAC40-73-450-A
Description: Based on record review and interview the facility failed to ensure on or within seven days prior to the day of admission a preliminary plan of care was developed to address the basic needs of the resident that adequately protected the resident?s health, safety, and welfare. The preliminary plan shall be developed by a qualified fed staff person and in conjunction with the resident, and, as appropriate, other individuals. The preliminary plan shall be identified as such and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: 1. During the resident record review with staff #2, the inspector found resident #2 who was admitted 12-4-18, had no ISP identified as the preliminary ISP on file that was completed on or within seven days of admission. The only ISP located on file on the day of the inspection (4-23-19), was the comprehensive plan signed by the developer on 2-25-19, over two months after the resident?s 12-4-18 admission. Staff #2 stated the plan had been reviewed with the spouse who also resides in the facility on 2-25-19, but the spouse wanted to review and discuss the document with other family members before signing. 2. The staff #2 acknowledged the 2-25-19, ISP was the only ISP on file.

Plan of Correction: Resident #2 Move in date 12/4/18. Preliminary POC initiated 12/3/18 in EHR. A paper copy was not printed and placed on chart.

All new residents? ISP will be completed as per standard (on date of admission or within a 7 day prior to date of admission). Copy of ISP will be placed on chart after review with resident/RP. ISP will be completed by certified clinician and reviewed by second certified clinician for accuracy.

Standard #: 22VAC40-73-450-C
Description: Based record review, document review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for five of ten residents. Evidence: 1. On 4-23-19 during the inspectors review of the sampled resident's records with staff #2 and #3, resident #5's uniformed assessment instrument (UAI) dated 10-14-18 indicated toileting assessed as mechanical help (mh)/human help (supervision). However a review of resident #3's ISP indicated only staff to provide supervision during toileting. 2. A review of resident #6's record with staff #2 revealed, resident #6's UAI dated 4-17-19 indicated toileting assessed as mechanical help/human help physical assistance). However, a review of resident #6's ISP indicated staff assist. Further review of resident #6's record revealed admission physical examination dated 10-25-18 noted physician's order for physical therapy. The resident's ISP dated 10-27-18, 10-30-18, 1-21-19 and 4-16-19 did not indicate this service. Staff #2 stated the physical therapy services were located in the therapy book. A review of the services with staff #2 on 4-24-19 did not include documentation of this ordered service. 3. A review of resident #7's record with staff #2 and #3 revealed the personal social data form for resident #7 indicated the resident is an organ donor. A review of resident #7's ISP dated 4-16-19 did not indicate resident's organ donor information. 4. A review of resident #8's record with staff #2 and #3 revealed the UAI dated 1-1-19 indicated walking assessed as not performed. A review of resident #8's ISP dated 11-28-18 did not indicate what services were to be provided and who would provide service; resident also assessed as heard of hearing not on ISP. 5. A review of resident #9's record with staff #3 revealed resident's UAI dated 11-30-18 indicated stairclimbing assessed as mechanical help/human help (supervison); however, the ISP dated 11-30-18 indicated use of handrail (mechanical help) only. 6. Staff #2 and #3 acknowledge ISPs did not include assessed need.

Plan of Correction: Resident #7 social data sheet noted organ donor. Resident driver license and resident interview stated resident was not an organ donor. Social data sheet for Resident #7 corrected. Resident #3, #5, #6, #7, #8, and #9 ISP corrected. 6/1/19

During assessment to identify resident needs, the social data form will be reviewed and updated as needs for accuracy. All completed resident ISP;s will be reviewed by a second certified clinician for accuracy.

Standard #: 22VAC40-73-450-F
Description: Based on record review, observation, and interview the facility failed to ensure individualized service plans (ISPs) were updated as needed and as the condition of the resident changed. The review and update shall be performed by a qualified staff person and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence 1. During a review of the residents records with staff #2, the inspector found the following : a. Resident #1's ISP dated 4-5-19 did not address the resident was an organ donor as noted on the social data form or the resident's mechanical soft diet and finger foods the doctor ordered 1-10-19. b. During interview the inspector was told resident #2's personal laundry was done by the spouse and the walker observed in the resident's room was used for walking short distance within the room or to assist with standing, neither were included on the ISP dated 2-25-19. Also the 2-25-19, ISP had not been updated to include the order dated 3-21-19 to elevate resident #2's legs when not in bed, or the 1/2 bed rails for positioning, or the cushion for the resident?s wheelchair or the fall mat observed beneath the resident is in bed. The ISP also did not address the resident?s hearing aid. 2. Staff #2 acknowledged resident #2's ISPs had not been updated as needed.

Plan of Correction: Resident #1 and #2 ISP will be updated for accuracy of residents' needs.

24 hour new order report will be ran daily by designee and reviewed for change of condition orders. Identified changes will be carried over to ISP as appropriate at time identified. Family/RP will be notified at time of change and signature obtained as agreed upon at time of notification.

Standard #: 22VAC40-73-650-B
Description: Based on record review, document review and staff interview, the provider failed to ensure the physician or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements shall include the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. On 4-23-19 following a medication pass observation, a review of resident #6's physician's orders was conducted with staff #2 and #3. During the review, it was revealed that the admitting physical dated 10-25-18 and the physician order dated 4-18-19 did not include the diagnosis for the following medications prescribed: (a) Lexapro, (b) Famotidine, (c) Keppra, (d) Lidocaine Patch, (e) Vitamin B-12 and (f) Risperdal. 2. Staff #2 acknowledged the individual written prescriptions in resident #6's record did not include the diagnosis or specific indication for the drug.

Plan of Correction: Resident #6 prescriptions did not contain diagnoses. MD notified for clarification.

Education provided to licensed staff to received orders on accepting a complete order and clarification of indication for use. Night shift nurse will check all orders received in the prior 24 hours for accuracy and indication for use/diagnosis. If absent, clarification will be sought. Each order will be stamped and signed for proof of review.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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