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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: April 26, 2022 , April 27, 2022 , May 2, 2022 and May 9, 2022

Complaint Related: No

Areas Reviewed:
22VAC40-73 PERSONNEL
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 EMERGENCY PREPAREDNESS

Comments:
Type of inspection: Renewal
An unannounced renewal inspection was conducted on-site on 4-26-22 (ar 07:30/dep 6:00p.m) and 4-27-22 (ar 09:45/dep 3:30 p.m). The facility census on 4-26-22 was 114, a tour of the facility was conducted, evening meal observed on 4-26-22, medication pass observation conducted on 4-26-22, emergency preparedness observed on 4-26-22, resident and staff records reviewed, and staff and resident interviews conducted. An exit meeting was conducted on both days of the inspection with the administrator. Requested documents received on 5-2-22. A final exit was conducted on 5-9-22 with the administrator and two other management staff members.
The Acknowledgement of Inspection form was sent via email to the administrator on 5-11-22.

The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.

If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.

Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.

Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.

Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.

The department's inspection findings are subject to public disclosure.

Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.

For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815or by email at willie.barnes@dss.virginia.gov

Violations:
Standard #: 22VAC40-73-260-C
Description: Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR was posted in the facility so that the information is readily available to all staff at all times.

Evidence:
1. On 4-26-22 during a tour of the facility with staff #1, the inspector inquired where the first aid/CPR listing was posted in the facility. It was revealed that document was not posted and readily available for all staff at all times.
2. On 4-26-22, staff #1 acknowledged the first aid/CPR listing of all staff with current certification was not available and posted.

Plan of Correction: 1. The facility has posted a current list of all staff who have current certification in first aid or CPR. The information is readily available to all staff.
2. The Nurse Educator will provide a monthly update of all team members who have been First Aid/ CPR trained.
3. The Nurse Managers will review the list quarterly to ensure all areas have been updated.
4. The Administrator/Designee check units randomly to ensure that an updated list is being maintained. Completed actions will be submitted to the QA Committee for analysis and recommendations.

Standard #: 22VAC40-73-310-H
Description: Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for three of eight residents.

Evidence:
1. Resident #5?s April 2022 medication administration record (MAR) documented resident prescribed Ativan. There was not a treatment plan for this psychotropic medication.
2. Resident #6?s March 2022 MAR documented resident prescribed Seroquel. The treatment plan dated 7-23-21 did not include this medication.
3. Resident #7?s April 2022 MAR documented resident prescribed Ativan. The treatment plan dated 5-27-21 did not include this medication.
4. On 4-26-22 and 5-9-22 during the exit meeting, staff #1 acknowledged the aforementioned residents? psychotropic treatment plans were not available in the residents? record.

Plan of Correction: 1. The provider for Resident #5, #6 and #7 have been notified to provide a treatment plan for all psychotropic medication.
2. Unit Manager and/or designee will perform an audit of 100% of all psychotropic medication orders to ensure that all prescribed orders have required treatment plans per state regulations.
3. All prescribers have been notified by written correspondence the administrator of the necessary components of a prescribed order for psychotropic medication. The Nurse Educator/designee will provide refresher training to nurses and RMAs on required information. Unit Manager and/or designee will review new medication orders to verify orders by the next business day to ensure each order contains all required information.
4. The Administrator/designee will conduct random audit of 5 physician order forms containing new orders weekly for 12 weeks to validate new orders contain all necessary components per state guidelines. All completed actions will be submitted to the QA Committee for analysis and recommendation.

Standard #: 22VAC40-73-380-B
Description: Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information document with the required information per the regulation was kept current for three of eight residents.

Evidence:
1. Residents #2 and #3 personal and social data document did not include the resident?s date of admission to the facility.
2. Resident #1?s social data advance directive section is blank. The record includes a POST- DNR document dated 11-26-19. Resident?s date of admission noted as 1-24-17.
3. On 4-26-22, staff #1 acknowledged the resident?s personal and social data document in the record did not include the date of admission and updated advance directive information.

Plan of Correction: 1. Residents #2 and #3?s personal and social data document have been updated to include the residents date of admission to the facility.
2. Unit Managers/ Designees will review 100% of social data sheets to ensure all necessary information has been updated.
3. Nurse managers will provide education to all LPNs/RMAs that when there is an update to any of the resident?s information to update it on the social data sheet.
4. The Administrator/designee will conduct random audit of 5 social data sheet forms monthly. All completed actions will be submitted to the QA Committee for analysis and recommendation.
5.

Standard #: 22VAC40-73-450-C
Description: Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessment needs for three of eight residents.

Evidence:
1. Resident #1?s Cardiology Report dated 2-18-22 documented resident?s allergies and reaction to Amlodipine, Lisinopril and Silicon. The record included a POST document noting the resident is a Do Not Resuscitate (DNR). The individualized service plan (ISP) dated 12-30-21 documented resident is a ?Full Code? and no allergies are noted. The record documented a physician?s order for physical therapy services, 1-26-22. The nurse?s notes on 1-26-22 at 1:30 also noted physical therapy services with a local home health agency. These needs were not addressed on the resident?s ISP.
2. Resident #2?s admission?s physical noted physical therapy/ Occupational therapy (PT/OT) evaluate, resident?s date of admission noted as 6-18-21. The record documented the last day of physical therapy was dated 11-5-21 and start of care date of 9-29-21. These services were not addressed on resident?s ISP dated 6-11-21.
3. Resident #6?s uniformed assessment instrument (UAI) dated 2-1-22 documented behavior pattern as appropriate. The ISP documented the resident wanders and displays abusive behaviors toward others.
4. Staff #1 acknowledged all assessed needs for the aforementioned residents were not addressed on the resident?s ISP.

Plan of Correction: 1. Resident #1, #2, and #6 ISP has been updated to include all assessed needs.
2. Unit Managers/designees will review 10 resident records monthly to validate ISPs consistently address the individualized needs of each resident.
3. Nurse Educator will provide refresher training on the ISP completion and review process.
4. The Administrator/Designee will audit five residents? annual ISP monthly for 3 months to ensure all needs are addressed on both documents and that staff are following the correct for updating ISPs. Completed actions will be submitted to the QA Committee for analysis and recommendations.

Standard #: 22VAC40-73-680-D
Description: Based on record review, observation and staff interviewed, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

Evidence:
1. On 4-26-22 during the medication pass observation with staff #6, resident #4?s Miralax documented resident?s mixture was to be given with 8 ounces of water, coffee, or juice. Staff was observed placing the powder mixture in a small cup and poured the water into the cup. I t was later learned that the cup used was a 3 ounce cup. The inspector reviewed the April 2022 medication administration and let the staff know that the medication was not given as ordered by the physician.
2. Staff #6 acknowledged the medication was given as ordered by the physician. The MAR documented 8 ounce of liquid and that amount was not used with the powder mixture/Miralax.

Plan of Correction: 1. The provider for Resident #6 clarified the order for Miralax to ensure that medication shall be administered in accordance with the physician?s or other prescribers? instructions.
2. Unit Manager and/or designee will perform an audit during medication administration with all LPN and RMAs to ensure that they are following the appropriate guidelines for medication administration.
3. The Nurse Educator will provide refresher courses for medication administration to all LPNs and RMAs.
4. The Administrator/designee will conduct random audit of medication administration passes for 12 weeks rotating units. All completed actions will be submitted to the QA Committee for analysis and recommendation.

Standard #: 22VAC40-73-680-K
Description: Based on record review and staff interviewed, the facility failed to ensure when medication aides administer the PRN medications the order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.

Evidence:
1. Resident # 2?s physician?s order dated 4-7-22 documented resident?s Ventolin HFA inhaler- two puffs by mouth daily every 4 to 6 hours as needed.
2. Staff #1 acknowledged resident #2?s aforementioned inhaler should have an exact hour and not a range.

Plan of Correction: 1. The provider for Resident #2 clarified the order for Ventolin HFA inhaler. The order has been updated to ensure that medication shall be administered in accordance with the physician?s or other prescribers? instructions.
2. Unit Manager and/or designee will perform an audit of all Physician Order sheets to ensure that the exact dosage, and the exact time frames the medication is to be given in a 24-hour period.
3. The Nurse Mangers will provide education to all LPNs and RMAs on the regulatory guidelines for medication in ALF facilities.
4. The Administrator/designee will conduct random audit of Physician Order sheets for 4weeks rotating units. All completed actions will be submitted to the QA Committee for analysis and recommendation.

Standard #: 22VAC40-73-960-C
Description: Based on observation and staff interviewed, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center shall be posted by each telephone shown on the fire and emergency evacuation plan.

Evidence:
1. On 4-26-22 during a tour of the facility, it was observed that the telephone numbers for emergencies, including Poison Control Center was not available where telephones were noted on the evacuation posting/ the nursing stations- assisted living and memory care unit.
2. Staff #1 acknowledged the .telephone number for emergencies, including Poison Control Center was not available near the telephones located in the nursing stations

Plan of Correction: 1. The facility has posted by each telephone the numbers for Fire Department, Rescue Squad/Ambulance, Police and Poison Control Centers.
2. The Maintenance Manager will conduct random audits of the units to ensure that all telephones have the appropriate numbers within view.
3. The Nurse Educator will provide an all-staff training on emergency telephone numbers and procedures.
4. The Administrator/designee will conduct random audit of various areas to ensure that all emergency numbers are posted. All completed actions will be submitted to the QA Committee for analysis and recommendation.

Standard #: 22VAC40-73-980-A
Description: Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all of the required items and ensure items with expiration dates must not have dates that have already passed.

Evidence:
1. On 4-26-22 during a check of the facility?s first aid kits for the vehicle and facility with staff #4 and #12, the hand sanitizer dated 1-2022 was expired for the first kits for the vehicle and facility.
The kit for the vehicle also needed, ointment/wipes, extra batteries and gauze pads. The facility kit also needed roller gauze and extra batteries.
2. Staff #4 and 12 acknowledged the first aid kits did not include all of the required items.

Plan of Correction: 1. The First Aid Kits found deficient during inspections have been audited to ensure that all required items are present. Expiration dates were checked to ensure compliance.
2. The Nurse Managers/designee will complete a 100% audit of all First Aid Kits to ensure that all required items are present and ensure that items with expiration dates are within compliance.
3. The Nurse Managers/designee will educate nurses on various sheets how to check kits and replace necessary items. All nurses will be training on monthly documentation needed to show where each First Aid Kit has been checked.
4. The Administrator/designee will conduct an audit of First Aid Kits monthly for three months to validate staff member compliance with all required trainings. All completed actions will be submitted to the QA Committee for analysis and recommendation.

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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