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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: Jan. 6, 2023

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-80 COMPLAINT INVESTIGATION

Comments:
Type of inspection: Complaint Storage of medication
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/06/2023 9:40am- 11:07am

The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.

A complaint was received by VDSS Division of Licensing on 10/27/2022 regarding allegations in the area(s) of:

Storage of medication

Number of residents present at the facility at the beginning of the inspection: 108

The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.

Number of resident records reviewed: 5

Number of staff records reviewed: 0

Number of interviews conducted with residents: 0

Number of interviews conducted with staff: 5

Observations by licensing inspector: The Licensing Inspector conducted an audit of the medication carts and observed several medication passes.

Additional Comments/Discussion:

An exit meeting will be conducted to review the inspection findings.

The evidence gathered during the investigation did not support the (allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. 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 Alyshia E. Walker, Licensing Inspector at (757)-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:
Standard #: 22VAC40-73-100-A
Complaint related: No
Description: Based on observation during on-site inspection and interview, the facility failed to implement their infection control policy.

Evidence:

1. While observing the morning medication pass escorted by Staff #1, Staff #3 did not wash or sanitize their hands in between administering medications to different residents.

2. Staff #3 did not use appropriate coughing etiquette or hand hygiene. The staff member coughed while administering medication and did not wash or sanitize her hands.

3. Staff #1 acknowledged that Staff #3 did not use appropriate hand hygiene.

Plan of Correction: Measures to prevent non-compliance from occurring again:

All LPNs and RMAs were provided with an in-service training on January 7, 2023, and again on January 19, 2023, covering proper medication administration and infection control measures when administering medications.

RMA Refresher Courses scheduled through Omnicare for February 1 and February 2.

Medication Pass Observations are scheduled daily to identify and ensure compliance with the standards as well as our Medication Administration Policy.

Persons responsible for implementation and/or monitoring preventative measures:

Director of Clinical Services, Assistant Director of Clinical Services and/or designee.

Standard #: 22VAC40-73-640-A
Complaint related: No
Description: Based on record review, observation, and interview with staff, the facility failed to ensure methods to ensure accurate count of all controlled substances.

Evidence:

1. During a medication cart audit on 1/6/2022, the pill count (14 pills) for Resident # 4?s Gabapentin 100mg medication did not match the number of pills listed on the control log (15 pills).

2. Staff #5 acknowledged administering the Gabapentin 100mg capsule at 9:00am but forgot to sign off on the control medication log. A review of the MAR for 01/06/2023, showed documentation the medication was administered.

Plan of Correction: Measures to prevent non-compliance from occurring again:

All LPNs and RMAs were provided with an in-service training on January 7, 2023, and again on January 19, 2023, covering proper medication administration to include always ensuring the accurate count of all controlled substances.

RMA Refresher Courses scheduled through Omnicare for February 1 and February 2.

Medication Pass Observations are scheduled daily to identify and ensure compliance with the standards as well as our Medication Administration Policy.

Persons responsible for implementation and/or monitoring preventative measures:

Director of Clinical Services, Assistant Director of Clinical Services and/or designee.

Standard #: 22VAC40-73-680-C
Complaint related: No
Description: Based on observation, the facility failed to ensure medications be administered no earlier than one hour before and no later than one hour after the facility?s standard dosing schedule, except for those drugs that are ordered for specific times.

Evidence:

1. During the on-site inspection escorted by Staff#1, Staff #3 administered medication to Resident # 2 at 10:08am. The medication administration record (MAR) verified the medications were scheduled to be administered at 9:00a.m.

2. Staff #3 acknowledged the medications for resident #2 were administered late.

3. A review of the January 2023 MAR for Resident #1 documented that the resident?s medications were administered late on 01/01/2023 (14 medications), 01/02/2023 (31 medications), 01/03/2023 (16 medications), and 01/05/2023 (15 medications).

4. A review of the January 2023 MAR for Resident #2 documented the resident?s medications were administered late on 01/05/2023 (2 medications).

5. A review of the January 2023 MAR for Resident #3 documented the resident?s medications were administered late on 01/01/2023 (14 medications), 01/03/2023 (13 medications), 01/04/2023 (13 medications), and 01/05/2023 (13 medications).

Plan of Correction: Measures to prevent non-compliance from occurring again:
All LPNs and RMAs were provided with an in-service training on January 7, 2023, and again on January 19, 2023, covering proper medication administration and the documentation of administration.

Director of Clinical Services & Assistant Director of Clinical Services have audited all resident MARs to ensure orders were entered in compliance with our facility standard dosing schedule, except for those drugs ordered for specific times to ensure compliance with the standard.

Director of Clinical Services & Assistant Director of Clinical Services completes daily audits of EMAR administration times to ensure compliance with the standard.

Persons responsible for implementation and/or monitoring preventative measures:
Director of Clinical Services, Assistant Director of Clinical Services and/or designee.

Standard #: 22VAC40-73-680-H
Complaint related: No
Description: Based on record review and interviews, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.

Evidence:

1. During the on-site medication cart audit escorted by Staff#1, several medications were observed pre-poured in a medication cup in the top drawer of the medication cart. Staff# 3 administered the medication to Resident #2.

2. A review of the MAR for Resident #2 has the medications as being administered at 9:30am, however Staff #3 administered the medications at 10:08am.

3. Staff #1 verified it was not common practice of the facility for medications to be pre-poured.

Plan of Correction: Measures to prevent non-compliance from occurring again:

All LPNs and RMAs were provided with an in-service training on January 7, 2023, and again on January 19, 2023, covering proper medication administration and the documentation of administration.

Medication Pass Observations and Med Cart Audits are completed daily to identify and ensure compliance with the standards as well as our Medication Administration Policy.

RMA Refresher Courses scheduled through Omnicare for February 1 and February 2.

Persons responsible for implementation and/or monitoring preventative measures:
Director of Clinical Services, Assistant Director of Clinical Services and/or designee.

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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