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: Feb. 18, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

A Licensing Inspector with the Department of Social Services conducted an unannounced, non-mandated, monitoring inspection on 02/18/2020. The inspection was in reference to a facility self reported incident. The Inspector arrived at approximately 9:50 am. The facility Administrator was available and present during the complete inspection. The Licensing Inspector interviewed staff, residents, reviewed resident records and additional facility documentation. The Licensing Inspector reviewed documentation provided by the local police department. Areas of non-compliance are found within this violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring preventative. Please contact the facility Licensing Inspector Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review the facility failed to ensure the comprehensive individualized service plan included: (1.) Description of the identified needs based upon the UAI. Evidence: During resident record review with staff #1 and #2 on 02/18/2020 documentation on resident #1's uniform assessment instrument dated 05/29/2019 indicated the resident was disoriented to place and date. When reviewing resident #1's individualized Service Plan documentation read, "Disorientation...will be re-oriented as needed ongoing and through 4/12/2020...remind and orient resident when confused and disoriented to date and time." The individualized service plan did not address the need for resident #1's disorientation to place.
Plan of Correction:	Resident placed on 2 hour rounding for location. 2/25/20 Specification on resident redirection when disoriented in relation to location specified on ISP. 2/19/20 All resident with disorientation were reviewed to ensure the comprehensive ISP included description of identified needs based on the UAI. 3/19/20
Standard #:	22VAC40-73-460-D
Description:	Based on documentation provided by the local police department, record review and staff interviews the facility failed to provide supervision of resident schedules, care and activities, including attention to specialized needs. Evidence: On 02/18/2020 documentation provided on resident #1 report of resident physical examination dated 01/11/2019 that resident #1 had "Late onset Alzheimer's disease without behavioral disturbance". Evidence #2: Based on several staff statements, resident #1 was often forgetful of resident #1's assigned room number. Evidence #3: When interviewing resident #1 with staff #2 on 02/18/2020, resident #1 could not recall resident #1's assigned room number. Evidence #4: Documentation provided by the local police department on 03/16/2020 reads, "Resident #1 was then seen by staff in the foyer around 1900 hours in mobility chair (wheelchair with four small wheels). Staff went to give resident #1 medication around 2100 hours, and resident #1 was not in resident #1's assigned room and could not be located. Evidence #5: Search teams including two local police department, k-9 unit, special victims unit, facility staff and outside community search support searched for the missing resident and local media was involved. Information was shared by facebook viewers and local news station. Evidence #6: Documentation provided by the local Police Department reads, "Update 2/17, at 1821 hours...A phone call from the facility revealed resident #1 had been located. When investigator return to facility, staff reported resident #1 was discovered in (a alternate) room. The facility director told investigators that (the alternate room) is a vacant room, and is normally locked. There was no explanation as to how resident #1 gained entry to the locked room, nor how resident #1 was missing in the room-to-room search. It is believe that resident #1 required assistance with bathing, dressing, transferring, meal prep, housekeeping, laundry, money management and medication administration.
Plan of Correction:	Resident located in apartment 312. 2/17/20 Resident placed on 2 hour rounding for location. 2/25/20 Specification on resident redirection when disoriented in relation to location specified on ISP. 2/19/20 All staff training on proper procedure for room search conducted. 3/19/20 All staff training on Code Orange conducted. 3/19/20