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: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring 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. 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 E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
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 (5 pills) for Resident # 4?s Acetaminophen-Codeine 300-30mg medication did not match the number of pills listed on the control log (6 pills). 2. Staff #2 acknowledged administering the Acetaminophen-Codeine 300-30mg medication at 9:00am but forgot to sign off on the control medication log. A review of the MAR for 03/10/2023, showed documentation the medication was administered.
Plan of Correction:	Measures to prevent non-compliance from occurring again: LPNs and RMAs were provided with an immediate in-service training on the date of the inspection covering proper medication administration to include always ensuring documentation of the accurate count of all controlled substances. 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 always ensuring the accurate count of all controlled substances. RMA Refresher Courses were previously scheduled and completed through Omnicare Pharmacy on February 1, 2023, and February 2, 2023. Medication Pass Observations are completed on a weekly basis at random to identify and ensure compliance with the standards as well as our Medication Administration Policy. Medication Pass Observations are completed by the Regional Director of Clinical Services during healthcare oversight visits and quarterly quality assurance audits. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services and/or designee. Date to be completed: 3/31/2023 and ongoing.
Standard #:	22VAC40-73-680-C
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. A review of the March 2023 Medication Administration Record (MAR) for the dates of March 1st through March 10th for Resident #1, documented that the resident?s medications were administered late on 03/01/2023 (1 medication), 03/02/2023 (1 medication), 03/03/2023 (1 medication), 3/4/2023 (8 medications), 3/5/2023 (1 medication), 3/6/2023 (1 medication), 3/7/2023 (9 medication), 3/8/2023 (1 medication), and 3/9/2023 (1 medication). 2. A review of the March 2023 MAR for Resident #2 documented that the resident?s medications were administered late on 03/01/2023 (1 medication), 03/02/2023 (1 medication), 03/03/2023 (4 medication), 3/4/2023 (6 medications), 3/5/2023 (2 medications), 3/6/2023 (1 medication), 3/7/2023 (2 medications), 3/8/2023 (1 medication), 3/9/2023 (5 medications) and 3/10/2023 (1 medication). 3. A review of the March 2023 MAR for Resident #3, documented that the resident?s medications were administered late on 03/01/2023 (3 medications), 03/02/2023 (12 medications), 3/4/2023 (12 medications), 3/5/2023 (5 medications), 3/7/2023 (2 medications), and 3/8/2023 (12 medications). 4. A review of the March 2023 MAR for Resident #4, documented that the resident?s medications were administered late on 03/01/2023 (12 medications), 03/02/2023 (8 medications), 03/03/2023 (8 medications), 3/4/2023 (8 medications), 3/5/2023 (8 medications), 3/6/2023 (8 medications), 3/7/2023 (8 medications), 3/8/2023 (8 medications), 3/9/2023 (8 medications) and 3/10/2023 (8 medications).
Plan of Correction:	Measures to prevent non-compliance from occurring again: LPNs and RMAs were provided with an immediate in-service training on the date of the inspection covering proper medication administration to include ensuring all medications are administered no earlier than one hour before and no later than one hour after the dosing schedule, except for those drugs that are ordered for specific times. LPNs and RMAs were provided with an in-service training on March 20, 2023, and again on March 22, 2023, covering proper medication administration practices. RMA Refresher Courses were previously scheduled and completed through Omnicare Pharmacy on February 1, 2023, and February 2, 2023. Medication Pass Observations are completed on a weekly basis at random to identify and ensure compliance with the standards as well as our Medication Administration Policy. Medication Pass Observations are completed by the Regional Director of Clinical Services during healthcare oversight visits and quarterly quality assurance audits. Medication Administration Audit Report pulled via EMR PCC 3-5x weekly by clinical leadership team to identify late administration of medications. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services and/or designee. Date to be completed: 3/31/2023 and ongoing.