Virginia DSS · Assisted Living Facility

The Hidenwood Retirement Community

📍 50 Wellesley Drive, Newport News, VA, 23606

ID 9045One Year licenseActive
11
Inspections
On record
8
With violations
Visits that cited something
3
Clean visits
Nothing cited
24
Violations cited
Individual findings
19
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

The Hidenwood Retirement Community was inspected 11 times between June 25, 2021 and May 20, 2025 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 24 violations under 19 distinct standards. 4 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 10 of these 11 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
06/27/2026
Administrator
Christopher Cook
Licensing inspector
Alyshia Walker
Inspector phone
(757) 670-0504
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

11

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 20, 2025Inspection2 violations
Inspection dates
05/20/2025
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: 5/20/2025 10:00 am- 5:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/27/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions without required documentation.
Evidence
  1. Resident # 2 has been prescribed the following psychotropic medications: Aripiprazole 5 mg (anxiety), Buspirone 150 mg (depression), Duloxetine 30 mg (depression), Lexapro 20 mg (depression), and Xanax 0.5 mg (anxiety). The resident record presented to the Licensing Inspector at the time of the inspection did not contain psychotropic treatment plans for the medications.
Plan of correction
Corrective Actions and Preventative Measures: The current community leadership team, including the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, and Director of Community Relations will ensure that all pre-admission interviews and required documentation are accurately completed in compliance with regulatory standards prior to a resident’s admission. The Director of Clinical Services and/or the Assistant Director of Clinical Services will be responsible for verifying that any resident prescribed psychotropic medications has an appropriate and up-to-date psychotropic treatment plan in place before admission, with ongoing updates as necessary throughout their residency. Persons responsible for implementation and/or monitoring preventative measures: Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, and Director of Community Relations
22VAC40-73-460-A
Based on resident record review, resident interview, and a review of resident medication, the facility has failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. On the initial physical dated 8/15/22024 for Resident #2, the question which asks, “Has the resident exhibited behaviors or patterns of behavior within the previous six months indicative of mental illness, mental retardation, substance abuse or behavioral disorders that caused, or continue to cause, concern for the health, safety, or welfare of either the applicant or others who could be placed at risk of harm by the applicant.” The healthcare provider checked yes.
  2. There was not Mental Health screening was located in the file presented to the licensing inspector at the time of the inspection.
  3. The progress notes of Resident #2 dated 10/9/2024, documented the resident’s inappropriate sexual verbalized advances that were made towards a housekeeping staff member.
  4. The progress note dated 10/9/2024 documented the resident’s healthcare provider advised the facility to “redirect the resident’s inappropriate behaviors.”
  5. The progress notes for Resident #2 dated 10/20/2024 stated, “The resident is exhibiting aggressive behavior towards female residents in facility. Resident has been making unwanted advances towards female resident, while knocking on their doors. Resident has been re-directed several times this shift from wondering and knocking on female residents’ door but continues to exhibit hostile behavior. MD has been faxed to advise this matter.”
  6. The progress notes for Resident #2 dated 10/28/2024, indicated the resident entered a female’ resident’s room without consent and acted sexually inappropriate.
  7. The facility initiated an immediate discharge of Resident # 2 on 11/1/2024 stating, “the basis of the discharge is we cannot meet the needs of the resident due to behaviors exhibited by the resident while at the community. Many of these behaviors pose a health and safety risk to the resident (name redacted), residents, and staff.
Plan of correction
Corrective Actions and Preventative Measures: The current community leadership team, including the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, and Director of Community Relations will ensure that all pre-admission interviews and required documentation are completed accurately and in full compliance with applicable regulatory standards prior to a resident’s admission. Residents presenting with conditions prohibited by these standards will not be admitted. Should a resident experience a significant status change, including the emergence of inappropriate or aggressive behaviors, they will be referred for evaluation at the Riverside Regional Medical Center Emergency Department. For residents who require redirection or exhibit behaviors that necessitate continuous supervision, a one-on-one team member will be assigned through the community’s Care Impact Program, as appropriate. Persons responsible for implementation and/or monitoring preventative measures: Executive Director, Director of Clinical Services, Assistant Director of Clinical Services
May 20, 2025Inspection1 violation
Inspection dates
05/20/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 5/20/2025 10:00 am-5:10 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/1/2025 regarding allegations in the area(s) of: Resident Care and Related Services Personnel Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: Number of interviews conducted with staff: 1 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
22VAC40-73-110-1
Based on the onsite record review the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled.
Evidence
  1. The Licensing Inspector received a self-report on 4/1/2025, from the facility regarding Staff #2 failing to provide immediate assistance for Resident #1 after the resident had falls on 3/27/2025 and 3/28/2025. The facility conducted an internal investigation and Staff #2 was terminated on 4/2/2025.
Plan of correction
Date Corrected: April 1, 2025 On April 1, 2025, at approximately 12:45 PM, the Executive Director was informed that the resident’s daughter was requesting a meeting. The Executive Director immediately met with the resident’s daughter at approximately 12:45 PM. The resident’s daughter expressed concerns regarding two recent falls that occurred on March 27 and March 28, 2025. The concerns centered on the inappropriate response and conduct of the assigned caregiver, as observed through the resident’s in-room electronic recording device. During a meeting with the Executive Director on April 1, 2025, the resident’s daughter presented the video footage from both incidents. Upon review, the footage clearly demonstrated caregiver negligence and failure to adhere to critical care procedures. As a result, the caregiver was immediately suspended pending a formal investigation. On April 1, 2025, a report was submitted to the VDSS Licensing Inspector, and a formal self-report was filed with Adult Protective Services (APS) through the online reporting portal. The internal investigation concluded on April 1, 2025, and the caregiver’s employment was officially terminated on April 2, 2025. The Executive Director provided a follow-up to the resident’s daughter at the conclusion of the investigation, confirming that the matter had been thoroughly reviewed and resolved with the caregiver’s termination. The resident’s daughter expressed appreciation for the prompt and appropriate response. On April 15, 2025, APS completed its investigation of the self-report filed on April 1. During the visit, the APS Family Services Specialist observed the resident, interviewed a current caregiver, and reviewed requested documentation. The Specialist commended the timely and effective handling of the situation and confirmed that the case would be closed, noting there was no physical harm to the resident and that corrective action had been taken. Throughout the investigation, the Executive Director maintained communication with the VDSS Licensing Inspector, providing regular updates. The final update was submitted on April 15, 2025, following the APS visit.
May 13, 2025Inspection5 violations
Inspection dates
05/13/2025, 05/20/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 5/13/2025 (7:54 am-3:16 pm), 5/20/2025 (10:00 am-5:10 pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 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
22VAC40-73-650-C
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. The record for Resident # 9 contained documentation of a written verbal order dated 2/16/2025, for the resident to have a change in diet (from mechanical soft to pureed) due to dysphagia, for the discontinuance of the resident’s benxonatate 100 prn for cough, and to start administering dextromethorphan-guaifenesin 100 mg-10 mg/5ml syrup (Robitussin DM)- 10 m. by mouth every 6 hours prn for cough. These orders were not signed by a physician or prescriber within 14 days of the verbal order.
  2. Staff # 2 acknowledged the resident’s record did not contain the signed physician’s orders at the time the licensing inspector was reviewing the chart.
Plan of correction
Corrective Actions and Preventative Measures: The Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) will review the PCC Order Recap Report daily for Verbal Orders received to ensure the orders are signed by a physician or other prescriber within 14 days per the standard. Verbal Orders received will be filed in a Verbal Order Binder in the nurse’s station for daily follow up by the Charge LPNs or RMAs to obtain a signature by the physician or other prescriber within 14 days and then filed in chronological order in the resident’s record. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services, Charge LPN, RMAs, and Designee(s)
22VAC40-73-450-D
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed.
Evidence
  1. The ISP for Resident # 9 dated 11/22/2024 did not include hospice services the resident is receiving.
  2. Staff #1 acknowledged the ISP for Resident #9 did not include the hospice services.
Plan of correction
Measures to prevent non-compliance from occurring again: Director of Clinical Services, Assistant Director of Clinical Services and/or designee will ensure that each residents’ ISP contains description of all identified needs and services through utilizing the electronic health record assessments, auditing UAIs to ISPs to ensure specific descriptions of assistance needed are listed and updating ISPs within 24-48 hours of any significant status change. Director of Clinical Services, Assistant Director of Clinical Services, and/or designee will audit (5) resident ISPs per week for compliance and update as necessary. Director of Clinical Services, Assistant Director of Clinical Services, and/or designee will ensure appropriate updates to resident UAIs, and ISPs are completed weekly following our Weekly Clinical Quality Assurance Meeting. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services, or designee
22VAC40-73-720-A
Based on the review of facility records, the facility failed to ensure that written Do Not Resuscitate Order is included in the individualized service plan.
Evidence
  1. Resident # 8 (date of admission 2/3/2025) has a Do Not Resuscitate Order dated 4/16/2025. The DNR is not included in the resident’s most recent ISP in the file which was presented to the licensing inspector during the inspection.
  2. Staff #1 acknowledged the DNR was not included in the ISP.
Plan of correction
Measures to prevent non-compliance from occurring again: Director of Clinical Services, Assistant Director of Clinical Services and/or designee will ensure that each residents’ ISP contains written Do Not Resuscitate Orders as received. Director of Clinical Services, Assistant Director of Clinical Services, and/or designee will complete a 100% audit of all resident code statuses and ensure the resident code status is current on the ISP both electronically and the hard copy on the resident record. Director of Clinical Services, Assistant Director of Clinical Services, and/or designee will randomly audit (10) resident ISPs per month for code status accuracy. Director of Clinical Services, Assistant Director of Clinical Services, and/or designee will ensure appropriate updates to resident UAIs, and ISPs are completed weekly following our Weekly Clinical Quality Assurance Meeting. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services, or designee
22VAC40-73-680-M
Based on observations made during the medication cart audit, the facility failed to ensure medications ordered for PRN administration were available to be administered.
Evidence
  1. During the inspection on 5/13/2025, the Licensing Inspector determined the prescribed PRN Benzonatate 200 mg for Resident # 1 and the PRN Miralax 17 gm for Resident # 7 were not available to be administered.
  2. Staff # 2, Staff # 3, and Staff # 8 acknowledged the medications were not available to be administered.
Plan of correction
Resident #7 (PRN Miralax 17gm): The medication was reordered and delivered to the community on the day of the inspection, May 13, 2025. The original order was received on December 13, 2024, and it was last requested/administered on December 14, 2024. Resident #1 (PRN Benzonatate 200mg): The medication order was discontinued on the day of the inspection, May 13, 2025. It was initially received on January 3, 2024, and last requested/administered on February 1, 2024. Corrective Actions and Preventative Measures: The Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) will review the PCC Clinical Dashboard weekly to identify PRN medications not administered in over 30 days and consult with the prescribing provider for possible discontinuation. The PCC Medication Administration Audit Report will be reviewed daily by the DCS and ADCS to ensure compliance with medication administration protocols and confirm all active orders are available on the medication cart. Monthly Medication Cart Audits will be conducted by the DCS and ADCS to ensure adherence to the community's Medication Administration Policy. LPNs and RMAs will participate in ongoing training on the community’s Medication Administration Policy to reinforce compliance. Omnicare will conduct quarterly reviews of the community’s staff responsible for administering medications to include medication administration observation and medication cart audit. This audit includes checking for any unavailable, outdated, damaged, or contaminated medications. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services, Charge LPN, RMAs, and Designee(s)
22VAC40-73-650-E
Based on a review of resident records and interviews with staff, the facility failed to ensure the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order and that orders shall be organized chronologically in the resident's record.
Evidence
  1. The April 2025 Medication Administration Record for Resident # 9 documented the resident’s Metoprolol Tartrate 25 mg tablet was held from 4/2/2025 to 4/9/2025 and discontinued on 4/14/2025. The Licensing Inspector did not find the order for the medication to be held or discontinued filed in the resident’s record. Staff # 2 examined the resident record and was not able to locate the order. Staff #2 was able to provide a discontinuation order later during the inspection. The order was not in the resident record which was presented to the licensing inspector at the time of the inspection.
Plan of correction
Corrective Actions and Preventative Measures: The Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) will review the PCC Order Recap Report daily for Verbal Orders received to ensure the orders are signed by a physician or other prescriber within 14 days per the standard. Verbal Orders received will be filed in a Verbal Order Binder in the nurse’s station for daily follow up by the Charge LPNs or RMAs to obtain a signature by the physician or other prescriber within 14 days and then filed in chronological order in the resident’s record. Persons responsible for implementation and/or monitoring preventative measures: Director of Clinical Services, Assistant Director of Clinical Services, Charge LPN, RMAs, and Designee(s)
May 21, 2024Complaint survey2 violations
Inspection dates
05/21/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 5/21/2024 9:10 am- 5:30 pm 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 1/9/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the (allegation(s)/self-report) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also 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 Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a review of facility records, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The Medication Admin Audit Report for Resident #3 lacked documentation that prescribed medication was administered on the following days and times: 6/5/2023 9am 6/19/2023 5pm 6/24/2023 9am 7/8/2023 3pm, 6pm, 8pm 8/1/2023 3pm, 6pm 8/14/2023 3pm, 6pm, 8pm 8/19/2024 6pm, 8pm 8/28/2023 3pm, 6pm, 8pm 8/31/2023 3pm, 6pm 9/2/2023 3pm, 6pm, 8pm 10/8/2023 7am, 9am, 10 am 10/8/2023 7am, 9am, 10am 10/18/2023 3pm, 6pm, 8pm 10/21/2023 7am, 8am, 9am, 10am, 3pm, 6pm, 8pm 11/9/2023 12 am 11/11/2023 6pm, 9pm 11/12/2023 6pm, 9pm 11/15/2023 6pm, 9pm
  2. The Progress Notes for Resident #3 documented a conversation between the resident and a staff member. The Progress Note states, “Resident stated that staff suppose to administer her medication and that not being done”.
  3. Resident #3’s Progress Notes do not document medications being held by the physician on the above days and times.
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 per MD orders unless a hold order or discontinue order is received by the MD. Staff will document resident refusals when attempts to administer medications per MD orders are unsuccessful in the progress notes and inform the MD. 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.
22VAC40-73-680-C
Based on records reviewed, the facility failed to ensure medication be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. A review of the Medication Admin Audit Report for May 1, 2024 through May 21, 2024, for Resident #1, documented the resident received 30 doses of medication later than the standard dosing schedule.
  2. A review of the Medication Admin Audit Report for May 1, 2024 through May 21, 2024, for Resident #2, documented the resident received over 90 doses of medication later than the standard dosing schedule.
Plan of correction
Measures to prevent non-compliance from occurring again: On the date of the inspection, LPNs and RMAs were provided with immediate in-service training covering proper medication administration, including 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. Medication Pass Observations are completed weekly at random to identify and ensure compliance with the standards and 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.
May 21, 2024Inspection7 violations
Inspection dates
05/21/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 5/21/2024 9:10 am- 5:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 4 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
22VAC40-73-350-B
Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident # 5 had an admission date of 2/21/2024 and the Sex Offender Screening was conducted on 4/16/2024.
Plan of correction
Measures to prevent non-compliance from occurring again: • Prior to the contract signing, all residents will have a Sex Offender Registry Search completed and in their business file by the Director of Community Relations. • Executive Director will audit and verify the Sex Offender Registry Search was completed and in the business file prior to contract signing. • Business Office Manager will audit and verify the Sex Offender Registry Search was completed in the business file once the business file is received from the Executive Director. • A full audit of all current residents will occur to ensure there is a current sex offender registry search completed, printed and within their business file. Persons responsible for implementation and/or monitoring preventative measures: • Executive Director, Director of Community Relations, Business Office Manager
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. A review of the Controlled Substance Verification/Shift Count Sheet for all of the medication carts in both the memory care and assisted living units documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff.
  2. Staff members #3 and #4 acknowledged the forms did not document narcotic medication counts were conducted during the change of each shift.
Plan of correction
• Staff education sessions will be held to educate the LPN/RMA staff on the Medication Management Policies, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes shift by documenting the complete of the shift-to-shift narcotic count sheet at the end/start of every shift. • Medication Pass Observations are completed weekly at random to identify and ensure compliance with the standards and 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. • Quarterly 3rd Party Medication Administration Observation to occur through Omnicare. Persons responsible for implementation and/or monitoring preventative measures: • Director of Clinical Services, Assistant Director of Clinical Services, Charge Nurses, Registered Medication Aides
22VAC40-73-550-G
Based on the review of facility records and staff interviews conducted the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. The file presented to the Licensing Inspector at the time of inspection for Resident #1 contained a review of resident’s rights dated 11/30/2022.
Plan of correction
Measures to prevent non-compliance from occurring again: • Business Office Manager will ensure that all residents and/or legal representatives receive a copy of the resident rights and responsibilities annually based on admission month for review and signature. • Business Office Manager will ensure that three attempts to obtain the resident and/or legal representative signature annually is documented within the resident record. • Business Office Manager will complete a full resident file audit to ensure all current residents have a signed resident rights and responsibilities acknowledgement within their file. • Business Office Manager will audit monthly to ensure compliance based on the resident’s admission month.
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified.
Evidence
  1. Resident # 4’s ISP dated 2/2/2023 stated the resident needed physical assistance with dressing. The resident’s UAI dated 1/16/2024 stated the resident required mechanical and human assistance with dressing.
  2. Resident #4’s ISP dated 2/2/2023 stated the resident needed supervision when toileting. The resident’s UAI dated 1/16/2024 stated the resident required mechanical and supervision when toileting.
  3. Resident #4’s ISP dated 2/2/2023 stated the resident needed mechanical and human assistance with stairclimbing. The resident’s UAI dated 1/16/2024 stated the resident does not perform stairclimbing.
  4. Resident #6’s ISP dated 5/6/2024 stated the resident does not walk due to general weakness. The residents UAI dated 9/27/2023 stated the resident required mechanical assistance only when walking.
  5. Resident #6 has a Do Not Resuscitate Order dated 5/13/2024 and the ISP dated 5/6/2024 stated the resident was a Full Code.
  6. Resident #6 is receiving Hospice services which are not reflected on the ISP dated 5/6/2024.
Plan of correction
Measures to prevent non-compliance from occurring again: • Director of Clinical Services, Assistant Director of Clinical Services and/or designee will ensure that each residents ISP contains description of all identified needs and services through utilizing the electronic health record assessments, auditing UAIs to ISPs to ensure specific descriptions of assistance needed is listed and updating ISPs within 24-48 hours of any significant status change. • Director of Clinical Services, Assistant Director of Clinical Services, and/or designee will audit (10) resident ISPs per week for compliance and update as necessary. Persons responsible for implementation and/or monitoring preventative measures: • Director of Clinical Services, Assistant Director of Clinical Services, or designee
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. On the date of the inspection 5/21/2024, Manager on Duty posting was not up to date as the posting listed individuals who were not in the building at the time the inspector started the inspection.
Plan of correction
Measures to prevent non-compliance from occurring again: Person in Charge Sign (Manager on Duty Signage) is at the Concierge Desk, on the wall. - Concierge coming in at 0800AM will call Nurse’s Station to see who is charge nurse for that time and will make sure the MOD sign has that person’s name in the MOD slot. -The Executive Director will notify the Concierge when they have arrived so the Concierge can change the MOD name to the ED’s name. --If the Executive Director is out of the office for the day, then the Director of Clinical Services will notify the Concierge of their arrival so the Director of Clinical Services name will be in the MOD slot. -At the end of the business day, the Person in Charge will notify the Concierge that they are leaving the building. The Concierge will then change the MOD name to the current Charge Nurse on duty. -At the change of the Charge Nurse’s shift, the new Charge Nurse will notify the Concierge that they are in the building and the Concierge will then change MOD name to the present Charge Nurse. -At the end of the Concierge’s shift at night, the Concierge will check in with the Charge Nurse to make sure the Person on Duty is current and correct. -If the Person in Charge changes after the Concierge has left, the Person in Charge will update their name on the posting. Persons responsible for implementation and/or monitoring preventative measures: -Executive Director, Concierge, Charge Nurses and/or designee
22VAC40-73-210-B
Based on the on-site record review and staff interview the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. (Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training).
Evidence
  1. The record for Staff #3, a registered medication aide, did not include documentation of 12 hours of annual training.
Plan of correction
Measures to prevent non-compliance from occurring again: • Business Office & HR Manager will review all team member monthly training hours due, overdue, and completed weekly, send a report to the Executive Director and department leaders, post a copy on the team member board and ensure follow up with team members occurs to schedule time in the community to complete required monthly training hours. • Business Office & HR Manager will review all current team member training hours for compliance with the standard by 7/31/24. Team Members will be removed from the schedule until all training hours are completed. Persons responsible for implementation and/or monitoring preventative measures: • Executive Director and Business Office & HR Manager
22VAC40-73-660-A
Based on observation and staff interviewed, the facility failed to ensure medication was stored in a manner consistent with current standards of practice.
Evidence
  1. During the on-site medication observation on 5/21/2024, the licensing inspector observed Melatonin, Loratadine 10ml, Tums, and Lotemax eyedrops on the dresser of Resident #8.
  2. Staff #4 acknowledged the resident is not able to self-medicate and Staff #3 acknowledged the medications were present.
Plan of correction
Measures to prevent non-compliance from occurring again: -Staff education sessions will be held to educate the LPN/RMA staff on Medication Storage. -The Omnicare General Medication Storage Guideline and audit form will be used to conduct weekly routine checks to ensure appropriate medication storage practices are being followed. -Weekly rounds on resident apartments and community for continuity of proper medication storage. Persons responsible for implementation and/or monitoring preventative measures: -Director of Clinical Services, Assistant Director of Clinical Services, Charge Nurses, Registered Medication Aides
March 10, 2023Inspection2 violations
Inspection dates
03/10/2023
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
22VAC40-73-640-A
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.
22VAC40-73-680-C
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.
March 10, 2023Complaint survey1 violation
Inspection dates
03/10/2023
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
22VAC40-73-640-A
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.
January 6, 2023Complaint survey0 violations
Inspection dates
01/06/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint ---- Buildings & grounds and Infection Control Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/06/2023 ]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 12/09/2022 regarding allegations in the area(s) of: Buildings & Grounds Infection Control 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. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 6, 2023Complaint survey4 violations
Inspection dates
01/06/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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
22VAC40-73-640-A
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.
22VAC40-73-680-C
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.
22VAC40-73-680-H
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.
22VAC40-73-100-A
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.
June 24, 2022Inspection0 violations
Inspection dates
06/24/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 6/15/22 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 110 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing Inspector observed medication passes, breakfast, lunch, activities, and toured resident rooms. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 25, 2021Inspection0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
The inspection was conducted by Licensing Staff using alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 06/25/2021 and concluded on 06/25/2021. The director or in-charge person was contacted by telephone to initiate the inspection. The inspector reviewed 4 resident and 4 staff records and additional documentation provided by the facility to ensure compliance. The information gathered during the inspection determined no violations with applicable standards or law. no violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.