VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bellaire at Stone Port
1684 Port Hills Drive
Harrisonburg, VA 22801
(540) 246-0888

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: July 25, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Technical Assistance:

None.

Comments:

The licensing inspector for Bellaire at Stone Port conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 7/11/19. Interviews were conducted with residents and staff relating to emergency response procedures. The information gathered during the investigation does not support the allegation, so the complaint is determined to be "not valid." There was one violation not reported but found during the inspection related to individualized service plans. Please complete the columns for "description of action to be taken" and "date to be corrected" for the violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258.

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based upon interviews and documentation, the facility failed to ensure the comprehensive individualized service plans (ISPs) included all of the assessed needs for four of the four resident records reviewed. Evidence: 1) The ISPs for the following residents did not include their needs as assessed on the uniform assessment instruments (UAIs): resident A - (admitted 9/22/18, ISP completed 9/22/18) did not include no added salt diet, mechanical and physical assistance with bathing, physical assistance with dressing and disorientation to time and place; resident B - (admitted 9/21/18, ISP completed 9/21/18) did not include mechanical and physical assistance with bathing and no concentrated sweets, low salt and soft food diet; resident C - (admitted 3/22/19, ISP completed 3/22/19) did not include mechanical assistance with bathing, toileting and transferring; resident D - (admitted 7/9/18, ISP completed 7/9/18 and 7/7/19) did not include mechanical assistance with bathing and eating, mechanical and physical assistance with walking, wheeling and stairs. 2) On 7/25/19, the licensing inspector (LI) interviewed the residents and executive director (ED) and all confirmed the needs as assessed on the UAIs.
Plan of Correction:	1) Resident A's ISP will be updated to include no added salt diet, mechanical and physical assistance with bathing, physical assistance with dressing and disorientation to time and place. Resident B's ISP will be updated to include mechanical and physical assistance with bathing and no concentrated sweets, low salt and soft food diet. Resident C's ISP will be updated to include mechanical assistance with bathing, toileting and transferring. Resident D's ISP will be updated to include mechanical assistance with bathing and eating, mechanical and physical assistance with walking, wheeling and stairs. 2) Moving forward, director of health and wellness (DHW), director of memory care (DMC), and other designees who have completed the Virginia UAI and ISP training will update ISPs for each resident to ensure description of identified needs are documented on the ISP. DMC and DHW have created an ISP cover sheet checklist to complete with interviewing and assessing residents to ensure that all required needs are assessed and documented on the ISP. The ED will review service plans with DHW and DMC to match with UAI and ensure all services are captured. 3) The DHW and ED will be responsible for monitoring and ensuring compliance with this standard is maintained.