Riverside Lifelong H & R Warwick Forest

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview was conducted with LPN #6. LPN #6 said that the unstageable sacral wound was first identified

on 7/09/25, as well as the stage 2 wound on the resident's buttocks. LPN #6 also said that she was not working on 7/09/25 and had assumed the resident's daughter had been notified of the wounds, but after conducting a chart audit, she did not see that the daughter had been contacted initially, but she notified her

on 7/21/25. LPN #6 also mentioned that the Director of Nursing (DON) notified hospice on 7/09/25. LPN #6 also said that it's not acceptable to first identify a wound as unstageable.On 8/22/25 at approximately 4:40 pm., an interview was conducted with the Director of Nursing (DON). The DON said that on 7/09/25, Resident #15's sacral area had yellow slough, and the buttocks had a sheared area. The DON also mentioned that she had called Hospice, not the resident's daughter.On 8/25/25, a pre-exit interview was conducted at approximately 11:40 am. The above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. They had no comments and voiced no further concerns regarding the above information

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Lifelong H & R Warwick Forest

1000 Old Denbeigh Boulevard Newport News, VA 23602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm

the excuse that the pharmacy hadn't sent it. Like I said, I didn't notice my pain any differently than any other time as I have chronic pain. The resident was asked if she had any further issues with her Gabapentin, and

she said, No, not really, just sometimes it seems a bit late, but they are doing pretty good most of the time.The Administrator was made aware of the concerns on 8/25/25 during the end of day meeting and no further information was provided.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Lifelong H & R Warwick Forest

1000 Old Denbeigh Boulevard Newport News, VA 23602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

A review of Resident #8’s General Hospital Discharge summary dated [DATE REDACTED] read: Assessment and Plan: closed nondisplaced fracture of second cervical vertebra, and closed nondisplaced intertrochanteric fracture of right femur. (Resident name) is a [AGE] year-old Caucasian gentlemen with a history of dementia who presented to the emergency department after sustaining an unwitnessed fall at his memory care unit where he resides. The patient sustained multiple traumatic injuries. For this reason the Trauma service was contacted regarding admission.

On 8/25/25 at approximately 1:05 PM, a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, Assistant Chief Nursing Officer, and Director of Clinical Education.

An opportunity was offered to the facility’s staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Lifelong H & R Warwick Forest

1000 Old Denbeigh Boulevard Newport News, VA 23602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and review of the clinical record, the facility staff failed to provide toileting upon request for 1 of 17 residents (Resident #2) in the survey sample. The findings included: Resident #2 was initially admitted to the facility on [DATE REDACTED], after an acute care hospital stay. The resident's current diagnoses included an L2 - L5 laminectomy and fusion, and left upper extremity edema secondary to a left cephalic vein superficial vein thrombosis.The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed; therefore, the following information was obtained from the N Adv - Clinical admission dated 8/12/25. The assessment revealed the resident had mild cognitive impairment (some confusion). The Mobility assessment dated [DATE REDACTED] revealed: Upper extremity (shoulder, elbow, wrist, hand): No impairment. Lower extremity (hip, knee, ankle, foot): No impairment.

Wheelchair (manual or electric). Roll left and right: admission Performance: Partial/moderate assistance. Sit to lying: admission Performance: Partial/moderate assistance. Lying to sitting on the side of the bed: admission Performance: Partial/moderate assistance. Sit to stand: admission Performance: Dependent.

Chair/bed-to-chair transfer: admission Performance: Dependent. Toilet transfer: admission Performance: Not attempted due to medical condition or safety concerns. Tub/shower transfer: admission Performance: Not attempted due to medical condition or safety concerns. Car transfer: admission Performance: Not attempted due to medical condition or safety concerns. A note on the whiteboard in the resident's room on 8/21/25 stated she required two persons assistance with transfers using the [NAME] Stedy lift.On 8/19/25 at 12:46 PM, Resident #2 was observed seated in a chair at bedside with her back brace lying on the bed. Resident #2 stated that she was constipated, but currently she had diarrhea. The resident further stated she had awakened with diarrhea up her back. The resident stated that she knows when she needs to use the toilet, but she was encouraged to wear an incontinence brief in case she had another accident. The resident also stated that most of the time, she was unable to get the staff to respond in time for her to utilize the toilet.

The resident stated she frequently had an accident because the nurses are unable to locate the lift ([NAME] Stedy) they use to transfer her with, or there is no nurse to assist the assigned nurse. Resident #2 stated that she will need to be able to toilet herself before returning home, as she will not have anyone to assist her. On 8/21/25 at 1:10 PM, the resident stated the toileting concerns had not changed, and she was still wearing incontinence briefs.An interview was conducted with the interim Rehabilitation Director (RD) on 8/20/25 at 12:25 PM. The RD stated that the rehabilitation team communicated the resident's ability to transfer to the nursing staff by writing on the whiteboard in the resident's room.On 8/25/25 at 10:50 AM, the above information was shared with the Administrator, Director of Nursing (DON), the Assistant DON, two Unit Managers, and the Assistant Chief Nursing Officer. The Administrator stated that there are sufficient [NAME] lifts in the facility, and each unit has one to two lifts. The Administrator also stated that two persons are not required to use the [NAME] lift; therefore, she would follow up on the reason the instructions were for two persons.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Lifelong H & R Warwick Forest

1000 Old Denbeigh Boulevard Newport News, VA 23602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

obtained for Pregabalin 75 mg capsules, give one capsule by mouth two times a day for pain. The Medical Director (MD) stated during an interview by phone on 8/25/25 at 12:21 PM, that the Acetaminophen, Lidocaine patch, and Pregabalin were ordered to treat Fibromyalgia pain, which is a challenging pain to treat. Also on 8/13/25 through 8/18/25, the resident had an order for Oxycodone HCl 5 MG (give 2.5 mg) by mouth every 8 hours as needed for pain. The resident received nine administrations for pain rated four through nine. On 8/18/25 at 3:15 PM, the resident received an order for Oxycodone HCl 5 MG (Give 2.5 mg) by mouth every 8 hours as needed for pain. The resident received a dose on 8/19/25 at 8:27 AM for pain rated ten out of ten.From 8/18/25 at 8:26 AM through 8/19/25 at 8:27 AM, Tylenol was the only pain medication received. On 8/19/25, a one-time dose of Oxycodone HCl 5 mg (give 0.5 tablet by mouth) was administered at 3:22 PM for pain rated ten out of ten. On 8/19/25, at 12:00 PM another order was received for Oxycodone HCl 5 mg, give one tablet by mouth every 4 hours as needed for pain. Fourteen doses were administered for pain rated five to ten out of ten.On 8/22/25 at 9:00 PM, an order was obtained for Oxycodone HCl ER 12 Hour Abuse-Deterrent Tablet 10 mg, give one tablet by mouth every 12 hours for severe pain for 5 days.An interview was conducted with the interim Rehabilitation Director (RD) on 8/20/25 at 12:25 PM. The RD stated that most of the time, a resident's therapy schedule is posted for staff to view and to ensure medication is administered to the resident accordingly. The RD also stated that Resident #1 had weight-bearing restrictions secondary to a compression fracture of the lower vertebra and a right wrist fracture resulting from a fall. The RD stated that the rehabilitation team communicated the resident's ability to transfer to the nursing staff by writing on the whiteboard in the resident's room. The RD further stated that the resident required one person's assistance to transfer to the wheelchair and to use the transfer bar to transfer to the toilet. A review of Resident #1's rehabilitation progress notes revealed that the resident did not miss any therapy days until 8/21/25. On 8/14/25, she exhibited nonverbal signs of pain. On 8/15/25, the resident was limited by pain. On 8/18/25 and 8/19/25, the resident complained of back pain, and on 8/20/25, she complained of left hip pain. The RD stated that whenever the resident experienced pain, the therapist reported it to nursing. The therapy documentation for 8/22/25 stated the resident continued to show improvement, but she was limited by back pain.On 8/21/25 at approximately 12:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) #12. LPN #12 stated she had administered pain medication to the resident earlier, and she had not reported any further pain, but she would follow up with

the resident.On 8/25/25 at 10:50 AM, the above information was shared with the Administrator, Director of Nursing (DON), the Assistant DON, two Unit Managers, and the Assistant Chief Nursing Officer. The Rehabilitation Unit Manager stated that she visits the resident daily, and she had never complained of pain to her.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Lifelong H & R Warwick Forest

1000 Old Denbeigh Boulevard Newport News, VA 23602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755

bit late, but they are doing pretty good most of the time.The Administrator was made aware of the concerns

on 8/25/25 during the end-of-day meeting, and no further information was provided.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Lifelong H & R Warwick Forest

1000 Old Denbeigh Boulevard Newport News, VA 23602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited RIVERSIDE LIFELONG H & R WARWICK FOREST in NEWPORT NEWS, VA for a deficiency under regulatory tag F-F0849 during a complaint investigation conducted on 2025-08-25.

Category: Administration Deficiencies

The facility was found deficient in the following area: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of RIVERSIDE LIFELONG H & R WARWICK FOREST.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-29.