VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Huntington
11143 Warwick Boulevard
Newport news, VA 23601
(757) 223-0888

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: Aug. 11, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/11/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Emailed on 8/14/2023 Number of residents present at the facility at the beginning of the inspection:29 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:4 Number of interviews conducted with residents: 3 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 #:	22VAC40-73-650-A
Description:	Based on record review and discussion, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: A review of the nurses? notes for Resident #5 documented by staff#8 that Voltaren gel was applied to the resident?s left had due to pain. The facility was unable to a physician?s order for the medication.
Plan of Correction:	1. The order for Voltaren gel for resident #5 was ordered on 4/20/23 and signed by the provider on 4/23/23. 2. Nursing staff will ensure that there are orders received by the provider before administering medications. 3. The Director of Nursing/ designee will review five resident records weekly for 6 weeks to ensure any new medications have orders in place from the provider. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the leadership team.
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview with staff, the facility failed to ensure the physician's or other prescriber's oral orders were reviewed and signed by a prescriber within 14 days. Evidence: 1. Resident #2 had had the following verbal orders: Turmeric supplement (ordered 7/25/23) and Omega supplement (ordered 7/25/23). There were orders signed by a physician or prescriber within 14 days of the verbal order in the resident?s record. 2. Resident #4 had the following verbal orders: Nitrofurantoin microcrystal 50 mg (ordered 6/26/23), Cephalexin 500 mg (ordered 6/26/23), Lantus Solostar U-100 Insulin 100 unit/ml two times daily (ordered 6/8/23), discontinuation order for hospital bed with half rails. There were no orders signed by a physician or prescriber within 14 days of the verbal order in the resident?s record. 3. Resident #5 had the following verbal orders: Artificial Tears (ordered 6/21/23), discontinuation order for Lidoderm 5% topical patch (ordered 7/7/23), discontinuation order for the resident to self-administer Pulmicort for nebulizer (ordered 8/8/23), discontinuation of magic cup at dinner (ordered 3/31/23), discontinuation of resident to self-administer all medications from pillbox (3/31/23). There were no orders signed by a physician or prescriber within 14 days of the verbal order in the resident?s record.
Plan of Correction:	1. The verbal orders for residents #1, 4, and 5 have been signed by the ordering provider. 2. A program was created to send an alert to the Resident Care Coordinator and the Director of Nursing of any verbal orders that have not been signed after 7 days so that they can follow up with the provider to ensure they are signed within the 14-day requirement. 3. The Director of Nursing/ designee will audit all new verbal orders weekly for 6 weeks to ensure the orders are signed within 14 days. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the leadership team