VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: June 28, 2019

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 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. 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:

Discussion occurred on the following topics: 1) Current fire inspection to be sent to licensing office upon completion. 2) Ensure resident council meeting information and minutes are posted on all units. 3) Ensure all glucometers are labeled with resident's name. 4) Review of hours required for dementia training. 5) Include socialization/activity component on the ISP. 6) Description of behaviors and interventions are to be included on the residents' ISP. 7) Policy and assessment system to be implemented for residents who self-administer medications. 8) Ensure use of EPI-pen and allergy is included on applicable resident's ISP.

Comments:

The information contained in this renewal inspection report will be reviewed by the licensing administrator. The facility will be notified by mail regarding their license status. A renewal inspection was conducted by two LIs on 06/28/2019 from approximately 8:30am until 4:15pm. There were 64 residents in care. A tour was immediately conducted. The building was free from any foul odors. All postings were current as were related drills. The activity schedule and lunch menu accurately reflected what the LIs observed. Ten resident, one discharge and five staff records were reviewed. Licenses and certifications were reviewed. Medication administration records were reviewed for a selected portion of residents. Interviews were conducted with residents and staff. There were nine violations during this renewal inspection. Details of non-compliance can be viewed in the violation notice of this report. If you have any questions, please contact the licensing inspector at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based upon review of staff records, the facility failed to ensure direct care staff attended six hours of cognitive impairment training within four months of employment. EVIDENCE: 1) The records for staff A and B did not contain any documentation of training in working with individuals with a cognitive impairment. 2) The facility has a mixed population and a secure environment for residents with a serious cognitive impairment.
Plan of Correction:	Failed to ensure Direct Care staff attended 6 hours of Cognitive impairment training within 4 months of employment. Records for staff A and B have completed their Cognitive Impairment. An audit tool has been created and a 100% audit is being conducted to ensure compliance with trainings, this will be completed by 11/5/19 by DON/ADON or designee. Also the orientation process has changed to where new employees are required to have their 6 hours completed in the first week which will be overseen by DON/ADON or designee.
Standard #:	22VAC40-73-120-A
Description:	Based upon review of staff records, the facility failed to ensure documentation of orientation and training is complete and maintained on file. EVIDENCE: 1) The record of initial training and orientation for staff A is not complete. a. The job description in record for staff A is not complete. 2) The record of initial training and orientation for staff B is not signed or initialed by trainer.
Plan of Correction:	Facility failed to ensure documentation of orientation and training is complete and maintained in file. Staff member A will have his record completed by 8/9/19. Staff B will sign initial training paper by 8/9/19An audit tool has been created and a 100% audit is being performed. This will be completed and corrections made by 11/5/19 by DON/ADON or designee.
Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, the facility failed to have annual TB risk assessment/screenings for all staff that document that the individual is free of TB in a communicable form as required by this section. EVIDENCE: 1) Documentation of last assessment/screening on file for staff D (hired 09/20/2012) is 05/22/2017. 2) There is no documentation of assessment/screening on file for staff E hired 12/11/2017.
Plan of Correction:	Facility failed to have annual TB risk assessment for all staff. Staff member D and E has completed Annual Risk assessment. An Audit tool has been created to track staff Annual TB risk assessments. 75% of the staff annual TB risk assessment forms have already been completed. DON/ADON will ensure the remaining are completed by 8/30/19. DON/ADON or designee will review the Audit tool monthly to determine any trainings, forms or annual requirements are needed and ensure completion.
Standard #:	22VAC40-73-350-B
Description:	Based upon review of residents' records, the facility failed to ascertain prior to admission, if a resident was a registered sex offender. EVIDENCE: There was no documentation of sex offender screening on file for resident A (admitted 06/25/2017), resident B (admitted 09/24/2018), Resident C (admitted 04/30/2019) and resident D (admitted 12/21/2018).
Plan of Correction:	Failed to ascertain prior to admission if a resident was a sex offender. Resident A, B, C, D sex offender has been pulled on 8/5/19 and filed in Medical record An audit will be completed of all residents to ensure that they have had a sex offender pulled. Administrator or designee will ensure prior to admission that the sex offender is pulled. A 100% audit will be conducted by 8/30/19 and corrections will be made by 8/30/19. A monthly audit will be conducted by DON/ADON or designee to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of residents' records, the facility failed to ensure the Individualized Service Plan (ISP) reflected the identified needs per the Uniform Assessment Instrument (UAI). EVIDENCE: 1) The UAI for C indicates mechanical assistance is needed for toileting. The types of mechanical supports needed are not identified on the ISP. 2) The UAI for resident D indicates use of hearing aids, glasses and assistance required with meals. This is not addressed on the ISP 3) The UAI for resident J indicates supervision is needed with meals. This is not addressed on the ISP. 4) The UAI for resident K indicates behaviors that are not identified on the ISP. a. The ISP for resident K does not indicate who changes O2 tubing and frequency. b. The ISP for resident K does not include current special diet order. 5) The UAI for resident L indicates wandering. This is not addressed on the ISP. 6) The ISP for resident M does not include name of home health agency, wound care and PT.. 7) The UAI for resident N indicates self administration of medications. The method for ensuring capability to self-administer is not included on the ISP.
Plan of Correction:	Facility failed to ensure the individualized service reflected the needs per the UAI Resident C, D, J, K, L, M, and N will be corrected by 8/9/19. Education will be provided to Nurses, ADON and DON by 8/9/19 to ensure that all changes are reported on LPN report sheet. The report will be reviewed daily for any changes that will need to be done to UAI/ISP. DON/ADON and designee will monitor for compliance.
Standard #:	22VAC40-73-550-G
Description:	Based upon review of residents' and staff records, the facility failed to ensure rights and responsibilities of residents were reviewed annually. EVIDENCE: 1) Documentation of last review for resident D is 04/14/2018. 2) There is no documentation of initial review of residents' rights on file for staff A hired 08/14/2018. 3) There is no documentation of annual review on file for staff D hired 09/20/2012. 4) There is no documentation of annual review on file for staff E hired 12/11/2017.
Plan of Correction:	Facility failed to ensure right and responsibilities of residents were reviewed annually in resident and staff record. Resident D was completed on 3/18/19. Staff A, D, and E have been completed. 75% of the staff annual Resident right forms have already been completed. DON/ADON will ensure the remaining are completed by 8/30/19. DON/ADON or designee will review the Audit tool monthly to determine any trainings, forms or annual requirements are needed and ensure completion.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' Medication Administration Records (MARs), the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. 1) Documentation in the MAR for resident J indicates medication refusals on all days except 06/14/19, 06/16/19 and 06/18/2019. There is no documentation of physician notification. a. Resident J has an order to administer Haloperidol scheduled every four hours. Documentation in the MAR indicates medication was not administered on 6/28/2019 at 12:00am due to "med error oversight, too close to next dose." b. Resident J has an order to administer Acetaminophen scheduled every 6 hours. Documentation in the MAR indicates medication was not administered on 6/28/2019 at 12:00am due to "med error oversight, too close to next dose. 2) Documentation in the MAR for resident G indicates Quetipine was not administered on 06/27/2019 at 8:00pm and on 06/28/2019 at 8:00am due to medication not being available. 3) Resident D has an order for compression stockings to be worn when patient is not lying down. Documentation in the MAR indicates the compression stockings were not available in the am on 06/20/19, 06/25/19 through 06/27/19 and not available in the pm on 06/21/19 through 06/27/19. a. Documentation in the MAR indicates compression stockings were applied on 06/19/19 in the am and pm ; and in the am 06/22/19 through 06/24/19. 4) Resident D has an order to administer Oxycodone if pain is not relieved by Tylenol. Documentation in the MAR indicates resident received Oxycodone on 06/19/19 at 11:52pm. There is no documentation Tylenol was administered on 06/19/19. a. Resident D has an order for Lactulose as needed for constipation. Documentation in the MAR indicates medication was administered on 06/08/19 at 4:46pm and on 06/09/19 at 12:38pm with no results. There is no documentation of follow-up in the MAR indicating medication was effective. 5) The MAR for resident B has documented refusals on 06/11/19, 06/14/19, 06/17/19 and 06/23/19. a. There is no documentation of physician notification.
Plan of Correction:	Facility failed to ensure medications are administered in accordance with the physician?s instructions and consistent with the standards of practice out-lined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Medication errors were found for Resident ?J?. No documentation to physician was found of residents refusals of medication. Resident had medication that was not given due to medication error of an oversight. Resident J has been scheduled for a medication review with Hospice on 8/5/19 and documentation will be provided. Education was also given to Med- tech L on 6/28/19 for missed doses of medication. Medication error for resident G. Medication not given for 2 doses due to medication not being available. This particular medication was just ordered on the day dose was missed. Education provided to Nursing staff on 8/5/19 to ensure that when a medication is ordered and entered in by pharmacy that the time entered to administer is appropriate. Education also given to Husband of resident on 8/5/19 due to him providing all her Meds from CVS. He was educated of the importance of the timeliness of getting her medication and the possibility that we may have to order from our pharmacy if he is not able to provide. Medication error for resident D. Received order for compression stockings to be applied. Compression stockings not available due to family waiting on the VA to provide. Order obtained 7/19/19 to put on hold till available. Nursing education provided to ensure that when item or equipment is not able to be obtained physician notification must be done and order to put on hold till available must be obtained. 4 staff members B, D, P, H also were found to have signed off as given when item was not available. 2 of the 4 staff members have been educated on 8/5/19 and the others will be educated by 8/9/19. Medication error for resident B. No physician notification of frequent refusals documented. Resident will be seen on 8/6/19 for medication review and documentation will be provided in Nurses Notes. Audit was conducted on 7/22/19 to identify any potential residents that could be affected by the same deficiency. Corrections were made that were warranted. Education is being provided to all Med Techs and Nurses and will be completed by 8/16/19. Audit tool in place and DON/ADON or designee will monitor weekly for any inconsistencies.
Standard #:	22VAC40-73-680-K
Description:	Based upon review of residents' Medication Administration Records (MARs), the facility failed to ensure PRN orders included all required information. EVIDENCE: The PRN orders for residents' B, D, F, G, H, I, and K do not consistently include instructions as to what to do if symptoms persist.
Plan of Correction:	The facility failed to ensure PRN orders included all the required information. PRN orders for B, D, F, G, H, I and K do not consistently include instructions as to what to do if symptoms persist. Residents listed above have been reviewed and corrected. An audit will be conducted and completed by 8/30/19 to review all prn medications and ensure all required information is present. Education will be provided to Nursing staff by 8/9/19 to ensure that any new prn that is ordered will include the required information. A monthly x 3 then quarterly audit will be conducted by the DON/ADON or designee to ensure we continue compliance.
Standard #:	22VAC40-73-700-1
Description:	Based upon review of residents' records, the facility failed to ensure oxygen orders included all required information. EVIDENCE: The oxygen orders for residents H, J and K do not identify source as it pertains to concentrator and/or portable tank.
Plan of Correction:	Facility failed to ensure oxygen orders included all required information. Resident H, J, K have been corrected on 7/3/19 and 7/9 An audit was conducted on all residents on oxygen on 7/3/19 and all orders have been corrected. Education will be given to Nursing staff by 8/9/19 to ensure any further oxygen orders indicate the source.