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: March 10, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/10/2023 1:45pm- 2:35pm 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 1/9/2023 regarding allegations in the area(s) of: Resident Care The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. 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 Alyshia Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medication was available in a timely manner to avoid missed dosages. Evidence: 1. On 3/10/2023 during an on-site inspection audit of the medication cart, with Staff #1 and Staff #4 Resident #6?s following PRN medications Enema and Glutose-15 40% gel were not available for administration during the inspection. 2. Staff #4 acknowledged the medications were not available for administration.
Plan of Correction:	Measures to prevent non-compliance from occurring again: Discontinue orders for both medications received on the day of inspection. LPNs and RMAs were provided with an immediate in-service training on the date of the inspection covering proper medication administration to include the ordering of medications per the residents? physicians? orders. LPNs and RMAs were provided with an in-service training on March 20, 2023, and again on March 22, 2023, covering proper medication administration to include ordering of medications per the residents? physicians? orders. Medication Cart Audits are completed by the RMAs, Charge Nurses, and clinical leadership team on a frequent basis to ensure all physician ordered medications are available. Residents and POAs were educated on the facility medication administration plan which states if a resident utilizes an outside pharmacy, and a medication is not available that our facility will order the medication through our contracted pharmacy, Omnicare, and the resident?s insurance will be billed accordingly to ensure residents that have outside pharmacies have medications always available per MD orders. Persons responsible for implementation and/or monitoring preventative measures: Charge Nurse, Director of Clinical Services, Assistant Director of Clinical Services and/or designee. Date to be completed: 3/31/2023 and ongoing.