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: Sept. 3, 2019 and Sept. 4, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Recommendations made and discussed on the following: 1) Recommended including a key on the activities calendar that explains what the different letters mean that indicate the location of the activity. 2) Answered questions about using room numbers instead of resident names on staff rounds; however, explained can indicate both but can not just use the room numbers. 3) When oxygen orders are renewed, ensure the new order includes the source (one of four oxygen orders did not include the source - resident U). 4) Ensure the expiration date is listed on the outside of the stat box and not just on the medications inside the box. 5) Recommended adding a section on the fire drill form for corrective actions taken for any problems. Note: There were no problems indicated on the fire drill forms completed since the last inspection. 6) Recommended making copies of appropriate information from the diet manual (which is kept in the staff office) to keep in the food preparation area. 7) Ensure when the staff in charge (SIC) calls out sick to designate a new SIC on the schedule. 8) Discussed reviewing all paperwork prior to filing to ensure all information is accurate and complete (such as do not resuscitate orders). 9) Two separate forms were used for all fire drills - one form consistently indicated am/pm with the time and the other form did not (for five of the nine drills reviewed). Ensure this form also indicates whether the time is am/pm. 10) Discussed documenting start date of volunteers and also when they stop coming in or take a break from coming in (as some of the volunteers were college students). 11) Ensure parameters are indicated for blood glucose monitoring, insulin administration, pulse and blood pressure monitoring as it relates to physician notification. Also, ensure all insulin orders include an area to document amount administered. 12) Recommended an additional review of special diet for resident K as it pertains to sodium measurement. 13) Ensure all as-needed orders include what to do if symptoms persist, symptoms versus symptomatic, and exact time of administration and strength (related to one resident).

Comments:

An unannounced renewal inspection was conducted on 9/3/19 from approximately 7:55 am to 7:15 pm with two inspectors and on 9/4/19 from approximately 7:40 am to 6:10 pm with one inspector. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. There were a total of 92 residents in care (with 23 in the memory care unit and 69 on the assisted living unit). There were a total of 10 direct care staff on duty (four on memory care and six on assisted living). The posted menu and activities calendar accurately reflected the inspectors' observations. Medication administration, medication administration records (MARs) and physicians' orders were observed for three residents. Ten additional MARs and physicians' orders were also reviewed. The criminal records checks were reviewed for all new current staff who were hired since the last inspection. Twelve resident, one discharge, one private sitter, two volunteer, two contract staff and eight staff records were reviewed. Selected sections of five additional resident and two additional staff records were also reviewed. Individual interviews were conducted with residents, family members, outside agency and facility staff. The areas of noncompliance included, staff schedules, fall risk ratings, sex offender registry annual reviews, individualized service plans, menus, medication storage, medication administration and maintenance of fixtures. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based upon documentation and an interview, the facility failed to ensure the staff schedules included the staff person in charge (SIC) at any given time. Evidence: 1) The staff schedule for 8/4/19 through 8/17/19 did not indicate the staff in charge for the 6:00 am to 2:00 pm shift on 8/4, 8/10, 8/11, 8/12, 8/13, 8/16 and 8/17; on 8/7 and 8/17 for the 10:00 pm to 6:00 am shift; and on 9/1 for the 6:00 am to 2:00 pm shift on the schedule for 9/1 through 9/14.
Plan of Correction:	After review, previous and current schedules were updated with the supervisor in charge indicated on the schedule. The scheduler and director of health and wellness (DHW) will review schedules weekly, prior to posting, to ensure SIC is listed. In the event of a call out, current SIC will update schedule with the new SIC prior to leaving shift. The DHW and scheduler will review schedules to ensure corrections were made. The DHW and scheduler will ensure implementation and monitoring of these measures.
Standard #:	22VAC40-73-325-B
Description:	Based upon record reviews and an interview, the facility failed to ensure four of the 13 residents' fall risk ratings were reviewed and updated annually. Evidence: 1) The last fall risk rating for resident A was completed on 5/2/18; resident C on 6/15/17; resident E had no fall risk rating on file; resident F on 7/24/18 2) On 9/4/19, the LI interviewed the administrator who stated they were updating the fall risk ratings after a fall and when the residents' condition changed; however, he stated they were not being done annually for all residents.
Plan of Correction:	The fall risk ratings for residents A, C, D, E and F were reviewed and updated. The DHW or designee will complete fall risk ratings for each resident annually, after each fall and as condition changes. Annual fall risk ratings will be completed in September and March to ensure compliance. The DHW will monitor completion of fall risk ratings assessments.
Standard #:	22VAC40-73-350-C
Description:	Based upon record reviews and interviews, seven of the 13 resident records reviewed did not include documentation of an annual review of the sex offender registry information. Evidence: 1) Residents A, C, D, E, F, K and M did not have documentation of this review during the past year. 2) On 9/4/19, the LI interviewed the administrator who stated the annual reviews had not been completed for the residents.
Plan of Correction:	Residents were given access to review the sex offender registry on 9/10/19 during the resident council meeting. Any residents missing were met with individually and given access to review the registry. Residents will be offered assistance with and have access to reviewing the sex offender registry annually when reviewing residents' rights. The executive director (ED) will monitor to ensure these steps are implemented.
Standard #:	22VAC40-73-450-C
Description:	Based upon documentation, the facility failed to ensure all assessed needs were included on the individualized service plans (ISPs) for 12 of 13 residents. Evidence; The following needs were not included on the residents' ISPs: Resident A (ISP updated 8/24/19) - money management and low concentrated sweets diet (ISP indicated a regular diet); resident C (ISP updated 4/9/19) low concentrated sweets diet and allergy to penicillin; resident D (ISP updated 8/24/19) - money management and allergies; resident E (ISP updated 8/7/19) - allergies, do not resuscitate order (DNR), ISP had full code, and mechanical assistance with bathing and wheeling; resident G (ISP updated 8/24/19) - medication administration, money management and allergies; resident H - money management, allergies and mechanical help with bathing; resident N - allergies, wandering, disorientation, type of mechanical assistance not identified; resident O - DNR, fall risk and allergies; resident P - hospice, mechanical assistance with toileting, dressing and mobility, mechanical and physical assistance with eating, supervision with wheeling and disorientation and abusive behaviors; resident Q - allergies, wandering, supervision with transferring, toileting and stair climbing.
Plan of Correction:	After reviewing the ISPs for residents A, C, D, E, G, H, N, O, P and Q, the missing information was added. The DHW, director of memory care and other designees who have completed the Virginia Uniform Assessment Instrument and ISP training, will review residents' current ISPs to ensure a description of identified needs are documented on the ISPs, including adding allergies and fall risk. A random selection of 10% of residents' charts will be audited monthly to ensure ongoing compliance. The DHW and director of memory care will be responsible to implement and monitor these measures.
Standard #:	22VAC40-73-610-B
Description:	Based upon observations and documentation, the facility failed to ensure the posted menu included snacks. Evidence: 1) On 9/3/19 during the facility tour, the current posted menu did not include snacks. The statement, "Assorted snacks available" was listed for each day; however, it did not indicate what the snacks were. 2) On 9/3/19, the LI interviewed the kitchen staff and the administrator and both confirmed that specific snacks that were available were not listed on the menu.
Plan of Correction:	The weekly menus were updated on 9/9/19 and posted to include a list of snacks available to residents. The director of dining services will list snacks available to residents on the bottom of each weekly menu prior to posting. The concierge will ensure the implementation and monitoring of these steps.
Standard #:	22VAC40-73-660-B
Description:	Based upon documentation, observations and an interview, the facility failed to ensure one resident's medications were stored so they were inaccessible to other residents. Evidence: 1) Resident F was assessed as capable of self-administering medications on the annual uniform assessment instrument completed on 7/23/19. 2) On 9/3/19, the LI interviewed resident F regarding storage of self-administered medications and showed this inspector the storage area. The medications were stored in a drawer in the living room area and the drawer was not able to be locked. Resident F's wife resides in the room also and has dementia.
Plan of Correction:	Resident F was provided a locking storage box on 9/3/19 and medications were immediately locked up. All residents who were self-administering were interviewed on 9/6/19 regarding safe keeping of medications. Residents and or family will purchase locking storage if needed and ensure medications are kept locked and out of sight. A lock box audit will be conducted quarterly along with the self-administer assessments. The DHW and shift supervisor will ensure implementation and monitoring of these steps.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation, the facility failed to ensure medications for seven of 13 residents were administered as ordered. Evidence: 1) Resident S had an order for Humalog 100 units (u) Kwikpen - inject per sliding scale before meals and at bedtime (HS). If blood sugar (BS) is 150-199 = 2u; 200-249 = 4u; 250-299 = 6u; 300-349 = 8u; 350-399 = 10u; 400-449 = 12u. Insulin was administered as follows: 8/6/19 at 4:00 pm BS level not documented but 6u administered; 8/7/19 at 11:00 am BS 227 - 2u; 8/7/19 at 8:00 pm BS 310 - 10u; 8/18/19 at 7:00 am BS 197 - 0u; 8/18/19 at 11:00 am BS 286 - 4u; 8/21/19 at 11:00 am - BS 206 - 6u; 8/22/19 at 8:00 pm BS 283 - 4u; 8/25/19 at 4:00 pm BS 261 - 8u; 8/26/19 at 7:00 am - BS 177 - two units not administered due to "outside parameters;" 8/27/19 at 7:00 am BS was not documented and no insulin was administered from the sliding scale order. Resident also had an order to inject 14u three times a day with meals. Documentation indicates 14u were administered; however, there was no recording of BS 8/7/19 at 7:00 am BS 266 - 4u; 8/28/19 at 8:00 pm BS 270 - 4u; 8/30/19 at 11:00am BS 267 - 8u;8/30/19 at 4:00 pm - BS 407 - 8u; 8/31/19 at 7:00 am - BS 217 - 2u were not administered due to "outside parameters"; 8/31/19 at 11:00 am - BS 258 - 4u. 2) Resident S had an order for Humalog 100u Kwikpen - inject 14u subcutaneously three times a day with meals - hold if BS is less than 100 and call physician (MD). Resident's BS was 194 on 8/10/19 and documentation indicated no insulin was administered due to "outside parameters;" on 8/27/19 at 7:00 am 14u were administered and no BS level was documented. 3) Resident D had orders for Lantus Insulin - inject 30u subcutaneously at bedtime and Humulin R 100u ml vial - inject 10u subcutaneously 10 minutes before lunch and dinner. Documentation in the medication administration record (MAR) consistently indicated Lantus and Humalog were not administered throughout the month of August due to being outside of parameters or resident had not eaten. There was no documentation in the MAR that MD was notified for instructions on parameters or if resident had not eaten. (Note: Resident was out of building 8/20/19 through 8/21/19). Resident D also had an order for Phenytoin Sodium Ext 100mg - take two capsules by mouth once daily. Documentation indicated medication was not administered on 8/21/19 as resident had not eaten. 5) Resident E had an order for BS checks weekly; however, no BS checks were documented on 8/12/19 and 8/19/19. Resident E had an order for blood pressure (BP) monitoring every morning prior to administering medications and document. There was no BP recorded on 8/10/19, 8/29/19 and 8/31/19 and the documentation on the MAR indicated "outside parameters." Resident E also had an order for Fluticasone spray - use one spray in nostril every day; however, documentation on MAR indicated medication was not administered on 8/10/10 due to being "outside parameters." 8) Resident K had an order for Novolog Mix 70-30 Flexpen - if BS is 180 or less, administer 5u prior to breakfast and dinner. Documentation on the MAR indicated the medication was administered on 8/8/19 through 8/13/19, 8/15/19, 8/16/19, 8/18/19 through 8/20/19, and 8/22/19 through 8/25/19 when BS level was greater then 180. BS was not taken on 8/26/19 due to "outside parameters." 9) Resident T had an order for Humalog 100u/ml vial - inject 4u subcutaneously with meals. Documentation indicated insulin was not administered on 8/1/19 and 8/8/19 at 6:00 pm due to "outside parameters." Resident also had a sliding scale order to administer 4u if BS was 200-249. Resident's BS was 206 on 8/10/19 at 11:00 pm and 6u were administered. Resident T also had an order for Cyanocobalamin monthly; however, the MAR indicated it was not administered. The MARs for resident P and U also had errors.
Plan of Correction:	Medication administration records from August for residents S, D, E, T, P and U were reviewed with physician/nurse practitioner. New process for creating insulin and blood sugar orders in the electronic health record was identified. An audit was conducted of insulin and blood sugar orders for all current residents by the DHW and all orders revised. Education was provided to registered medication aides (RMAs) and nurses on new order entry process. Medication administration education is being provided to all RMAs and nurses which focuses on administration of medications in accordance with physician instructions. Consultant pharmacist is conducting a focused medication regimen review for all current residents. A process was created to utilize Medication Dashboard in electronic health records as audit tool for daily review of medication administration by nursing of as-needed (PRN) medications administered and effectiveness, medications not administered and rational, potential of duplication of medications, and possible refills. The dashboard will be printed out and reviewed daily at shift huddles and stand up meetings for any trends or patterns and needed follow-up. Medication administration observations will be conducted by pharmacy. The DHW will ensure implementation and monitoring of these measures.
Standard #:	22VAC40-73-870-E
Description:	Based upon observations and an interview, the facility failed to ensure all commodes were kept in working order. Evidence: 1) During the facility tour, the LI checked the staff bathroom next to the 2B nurses station and observed the commode taped off indicating it was not working. 2) On 9/3/19, the LI interviewed a direct care staff who stated the commode had not been operational for almost a year. The LI also interviewed the administrator on this same day who also stated the commode had not been working for some time.
Plan of Correction:	The commode fixture in the bathroom next to 2B nurses' station will be removed and room will be converted into a soiled utility room. The maintenance assistant will ensure all furnishings, fixtures and equipment remain in working condition. Inoperable fixtures will be removed or replaced as needed. The director of environmental services will ensure implementation and monitoring of these measures.