Inspection Report
Monitoring
Census: 88
Deficiencies: 1
May 20, 2025
Visit Reason
The inspection was a monitoring visit conducted on May 20, 2025, following a self-reported incident received on April 1, 2025, regarding allegations in the areas of Resident Care and Related Services and Personnel.
Findings
The inspection determined non-compliance with applicable standards related to staff conduct and resident care. A violation was documented concerning staff failure to provide immediate assistance to a resident after falls, resulting in staff termination and corrective actions.
Deficiencies (1)
| Description |
|---|
| 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. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the monitoring visit |
| Executive Director | Informed and responded to resident's daughter's concerns, managed investigation and corrective actions | |
| Staff #2 | Caregiver terminated for failure to provide immediate assistance after resident falls |
Inspection Report
Monitoring
Census: 88
Deficiencies: 2
May 20, 2025
Visit Reason
The inspection was a monitoring visit conducted on May 20, 2025, following a self-reported incident received on October 27, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found non-compliance with applicable standards and laws, including failure to ensure required documentation for admitting or retaining individuals with prohibitive conditions and failure to assume general responsibility for residents' health, safety, and well-being. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions without required documentation, specifically lacking psychotropic treatment plans for Resident #2's medications. |
| Facility failed to assume general responsibility for the health, safety, and well-being of residents, evidenced by Resident #2's inappropriate and aggressive behaviors and inadequate mental health screening. |
Report Facts
Number of residents present: 88
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted the inspection and is contact for questions |
Inspection Report
Renewal
Census: 88
Deficiencies: 5
May 13, 2025
Visit Reason
The inspection was a renewal inspection conducted on May 13 and May 20, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to individualized service plans not being updated or complete, physician orders not signed within required timeframes, missing medication orders, unavailable PRN medications, and failure to include Do Not Resuscitate orders in service plans. Corrective actions and plans of correction were outlined for each deficiency.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed. |
| Facility failed to ensure physician's or prescriber's oral orders were reviewed and signed within 14 days. |
| Resident's record did not contain signed written order or dated notation of oral order, and orders were not organized chronologically. |
| Medications ordered for PRN administration were not available to be administered. |
| Written Do Not Resuscitate Order was not included in the individualized service plan. |
Report Facts
Residents present: 88
Resident records reviewed: 12
Staff records reviewed: 4
Resident interviews conducted: 3
Staff interviews conducted: 4
Resident ISPs audited weekly: 5
Resident ISPs audited monthly: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted the inspection |
| Director of Clinical Services | Responsible for implementation and monitoring of corrective actions related to deficiencies | |
| Assistant Director of Clinical Services | Responsible for implementation and monitoring of corrective actions related to deficiencies | |
| Staff #1 | Acknowledged deficiencies related to ISPs and DNR orders | |
| Staff #2 | Acknowledged missing signed physician orders and medication availability issues | |
| Staff #3 | Acknowledged medication availability issues | |
| Staff #8 | Acknowledged medication availability issues |
Inspection Report
Renewal
Census: 93
Deficiencies: 7
May 21, 2024
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to ensure required staff training hours, improper posting of the person in charge, incomplete sex offender screening prior to admission, deficiencies in individualized service plans, failure to review resident rights annually, medication management issues including controlled substance counts, and improper medication storage.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure all direct care staff attended required annual training hours. |
| Facility failed to ensure posting of the name of the current on-site person in charge was up to date. |
| Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender. |
| Facility failed to ensure each resident's individualized service plan contained a description of all needs/services identified. |
| Facility failed to ensure the rights and responsibilities of residents were reviewed annually with each resident or legal representative and staff. |
| Facility failed to implement its written plan for medication management regarding accurate counts of controlled substances during staff changes. |
| Facility failed to ensure medication was stored in a manner consistent with current standards of practice. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Registered Medication Aide | Named in deficiency related to failure to document 12 hours of annual training and medication count issues |
| Staff #4 | Named in medication count and medication storage deficiencies | |
| Executive Director | Responsible for implementation and monitoring of corrective actions | |
| Business Office & HR Manager | Responsible for monitoring training hours and compliance | |
| Director of Clinical Services | Responsible for clinical corrective actions including ISP audits and medication management | |
| Assistant Director of Clinical Services | Responsible for clinical corrective actions including ISP audits and medication management | |
| Director of Community Relations | Responsible for sex offender registry searches | |
| Business Office Manager | Responsible for auditing resident rights and sex offender registry compliance | |
| Charge Nurses | Responsible for medication management and monitoring | |
| Registered Medication Aides | Responsible for medication management and monitoring |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
May 21, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on January 9, 2024, regarding allegations in the area of Resident Care and Related Services at The Hidenwood Retirement Community.
Findings
The investigation supported the allegations of non-compliance with standards related to medication administration. Violations were issued for failure to administer medications within the facility's standard dosing schedule and failure to ensure medications were administered according to physician or prescriber instructions.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with medication administration standards.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medication was administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except for drugs ordered for specific times. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Residents present: 93
Resident records reviewed: 3
Medication doses late for Resident #1: 30
Medication doses late for Resident #2: 90
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 10, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 9, 2023, regarding allegations in the area of Resident Care.
Findings
The inspection found non-compliance with applicable standards related to medication availability, specifically that certain PRN medications were not available for administration during the inspection.
Complaint Details
Complaint related: Yes. A complaint was received on 1/9/2023 regarding Resident Care. The evidence gathered determined non-compliance and violations were documented.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medication was available in a timely manner to avoid missed dosages. |
Report Facts
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
Inspection Report
Monitoring
Census: 6
Deficiencies: 2
Mar 10, 2023
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with resident care and related services standards at The Hidenwood Retirement Community.
Findings
The inspection found non-compliance with applicable standards related to medication administration, including inaccurate controlled substance counts and medications administered outside the prescribed time frames. The facility was cited for these violations and provided plans of correction including staff training and ongoing monitoring.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure accurate count of all controlled substances. |
| Facility failed to ensure medications were administered no earlier than one hour before and no later than one hour after the facility's standard dosing schedule, except for drugs ordered for specific times. |
Report Facts
Number of resident records reviewed: 6
Number of staff interviews conducted: 3
Medication administration late counts: 70
Pill count discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted the inspection and authored the report |
| Director of Clinical Services | Responsible for implementation and monitoring of corrective measures | |
| Assistant Director of Clinical Services | Responsible for implementation and monitoring of corrective measures | |
| Staff #2 | Acknowledged administering medication but failed to sign off on control medication log |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 4
Jan 6, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2022-10-27 regarding allegations related to storage of medication at The Hidenwood Retirement Community.
Findings
The investigation did not substantiate the complaint allegations of non-compliance with standards or law. However, several violations unrelated to the complaint were identified, including failures in infection control, accurate controlled substance counts, medication administration timing, and documentation on medication administration records.
Complaint Details
Complaint was related to storage of medication. The evidence gathered did not support the allegation(s) of non-compliance with standards or law.
Deficiencies (4)
| Description |
|---|
| Facility failed to implement infection control policy during medication administration, including lack of hand hygiene and coughing etiquette by staff. |
| Facility failed to ensure accurate count of all controlled substances; pill count discrepancies and missing signatures on control logs were observed. |
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing times. |
| Facility failed to document all medications administered to residents on the medication administration record (MAR), including over-the-counter medications and dietary supplements. |
Report Facts
Number of residents present: 108
Number of resident records reviewed: 5
Number of staff interviews conducted: 5
Medication late administrations: 14
Medication late administrations: 31
Medication late administrations: 16
Medication late administrations: 15
Medication late administrations: 2
Medication late administrations: 14
Medication late administrations: 13
Medication late administrations: 13
Medication late administrations: 13
Pills discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Jan 6, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2022-12-09 regarding allegations related to buildings and grounds and infection control at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law in the areas of buildings and grounds and infection control.
Complaint Details
Complaint received on 2022-12-09 regarding buildings and grounds and infection control; the allegations were not substantiated.
Inspection Report
Renewal
Census: 110
Deficiencies: 0
Jun 15, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant, observed medication passes, meals, activities, and resident rooms, and reviewed resident and staff records.
Report Facts
Resident records reviewed: 7
Staff records reviewed: 6
Resident interviews conducted: 2
Staff interviews conducted: 4
Inspection Report
Renewal
Deficiencies: 0
Jun 25, 2021
Visit Reason
A renewal inspection was initiated and conducted on June 25, 2021, to ensure compliance with applicable standards and laws for The Hidenwood Retirement Community.
Findings
The inspection, conducted remotely due to a state of emergency health pandemic, reviewed resident and staff records and found no violations of applicable standards or laws.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
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