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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: Aug. 19, 2019

Complaint Related: No

Areas Reviewed:
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
An unannounced IPOC monitoring inspection was conducted by the Licensing Inspectors from the Eastern Regional Office and Peninsula Licensing Office on 08-19-2019 from 10:51 AM to 5:10 PM. There were 129 residents in care at the time of the inspection. A spot check of the medication carts on the Assisted Living Unit and Special Care Unit, and 6 resident records were reviewed. The facility received violations "under" Resident Care and Related Services. The areas of non compliance were discussed with the Administrator throughout the inspection and during the exit interview. The following was also discussed: MAR's, side rails, and the facility's Certificate of Occupancy. 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 09-19-2019.

Violations:
Standard #: 22VAC40-73-480-C
Description: Based on record review and interview, the facility failed to arrange for specialized rehabilitative services by qualified personnel as needed by the resident.
Evidence:
1. During resident #3?s record review with staff #1, the resident admitted to the facility on 07-31-2019. The admission physical examination was signed and dated by the physician on 07-25-2019, documenting the resident has a diagnosis of ?lumbar compression fracture-routine Percocet, PT/OT.? The physical examination also documented ?Therapy: PT/OT eval and treat;? however, there was no documentation on file to indicate the facility arranged for Physical Therapy (PT) and Occupational Therapy (OT) services; or to verify that resident #3 was evaluated and treated by PT or OT.
2. During interview, staff #1 could not provide documentation to verify resident #3 was evaluated or treated by PT/OT. Staff #1 confirmed the facility did not arrange for therapy services recommended by the physician.

Plan of Correction: Resident # 3?s chart was reviewed. New order requested from the physician and Physical Therapy team will be notified of PT/OT orders.
A 100% audit of residents who were admitted in the last three months will be completed to ensure residents with therapy orders on admission have received therapy services
An admission checklist was developed by the administrator/designee to review physician?s orders upon admissions by the nurse managers/designee within 24 hours.
Admissions personnel will be re-educated by the facility educator/designee regarding ensuring completeness of new resident?s orders. Nursing staff will be re-educated by the facility educator/designee regarding follow-up of all admission orders, including therapy orders.
Administrator/ designee will audit a minimum of 2 admissions monthly for 3 months to ensure completeness of documentation, to include ensuring admission orders are carried out and documented correctly. All findings will be 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 resident record review with staff #1 and staff #2, the August 2019 MAR?s for resident #1 and resident #2 were left blank on the following dates and did not include the date, time given, or staff initials for the following medications:
a. Resident #1?s Risperidone 0.25mg tab and Tramadol 50mg tab during the 0007 administration time on 08-18-2019; and Desitin Cream 13% and Eucerin lotion during 3p-11p on 08-18-2019.
b. Resident #2?s Acetaminophen 325mg tab during the 1200 administration time on 08-18-2019 and during the 0000 administration time on 08-19-2019.
2. During interview, staff #1 and staff #2 acknowledged the dates on resident #1 and resident #2's August 2019 MAR?s were blank and did not include the date, time given, and initials of staff.

Plan of Correction: Resident #1 and Resident #2?s MAR were reviewed by the nurse manager/designee. Resident observed by the unit manager. No negative effect noted. The resident?s physician was notified of the missed documentation of medication administration. A 100% audit of the current month of all residents? MAR for missed documentation was performed by unit managers/designee. All findings will be reported to the QA Committee for continued improvement and analysis.The Administrator will implement a red vest program to limit distraction during medication pass.
The Administrator/designee will evaluate medication times and opportunities to eliminate unnecessary or duplicate orders. All recommendations will be brought to the residents? attending physicians.
Re-education regarding medication administration documentation with clear expectation that the MAR is signed while the nurse is verifying the pill with the MAR (not after administration) will be provided to the nursing staff by the facility educator/designee.
The Administrator/designee will audit 12 MARs per week for four weeks then monthly for 3 months to ensure no holes are present. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

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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