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: Nov. 12, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS

Technical Assistance:

Topics discussed with the administrator: 1) The need for a full audit of all individualized service plans (ISPs) to ensure all needs are included. Also, recommended at least two people review the ISPs prior to having the resident or family member sign. 2) Posting the current weekly menu so it is visible to family members. 3) Conduct an in-service to remind staff that even though the medication cart may be positioned in the nurses station so others can not see the electronic medication administration records (eMARs) that are on top of the cart, when leaving the nurses station the eMARs must be closed out/shut down. 4) The hole left in the floor where the commode was removed must be plugged/covered until the area is completely fixed. NOTE: This area was for staff use only. 5) Ensure staff B provides a copy of her direct care training or completes the direct care aide class by 1/5/20.

Comments:

An unannounced non-mandated monitoring inspection was conducted as a follow-up to a previous inspection. Medication administration observations were completed with three residents and the medication administration records and physicians' orders were reviewed. Selected sections of 19 resident and 11 staff records were reviewed. Three of the eight previous violations were recited in the areas of fall risk ratings, individualized service plans and storage of self-administered medications. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based upon documentation and interviews, the facility failed to ensure a fall risk rating was conducted for one of 15 residents' records reviewed. Evidence: 1) Resident K fell on 10/17/19, 10/23/19 and 10/27/19; however, fall risk ratings were not completed for these falls. 2) On 11/12/19, the LI interviewed the director of nursing and administrator and both stated fall risk ratings were not completed for these three falls.
Plan of Correction:	1) Fall risk rating for resident K was reviewed and updated. 2) Education will be provided to nurses about the need to complete a fall risk rating after a resident encounters a fall. 3) DHW or designee will ensure fall risk rating is complete whenever a resident encounters a fall. 2) New process of weekly review by DHW and director of memory care (DMC) of residents who have encountered a fall that week to ensure updated fall risk ratings are completed and interventions reflected in the individualized service plans (ISPs). 5) The DHW and DMC will ensure the implementation and monitoring for these preventative measures.
Standard #:	22VAC40-73-450-C
Description:	Based on documentation, the facility failed to ensure seven of the 15 ISPs reviewed were updated to include all of the assessed needs of the residents. Evidence: The ISPs did not include the following: for resident D (completed 8/24/19) it still did not include money management and low concentrated sweets (LCS) diet; for resident E (completed 4/9/19) it still did not include LCS diet and allergies; for resident G (completed 8/24/19) and H (completed 8/24/19) money management and allergies; for resident I (completed 8/20/19) allergies, wandering and disorientation; resident J (completed 8/23/19) fall risk and allergies; resident K (completed 8/20/19) allergies, wandering and supervision with transferring and stair climbing.
Plan of Correction:	1) The missing information was added to the current ISPs for residents D, E, G, H, I, J and K. 2) DHW, DMC and other designees (who have completed the Virginia Uniform Assessment Instrument Training and ISP Training) will review residents' current ISPs to ensure description of identified needs are documented on the ISPs. A random selection of 10% of residents' charts will be audited monthly to ensure ongoing compliance. 3) The DHW and DMC will be responsible for the implementation and monitoring of these preventative measures.
Standard #:	22VAC40-73-660-B
Description:	Based upon observations, the facility failed to ensure one of four residents stored their medications so they were inaccessible to other residents. Evidence: 1) On 11/12/19, the licensing inspector (LI) along with staff entered resident P's room and observed bottled medications on a shelf and on a table in the living room. Resident P shares a room with a resident who has been diagnosed with dementia and the medications were accessible to this resident. 2) A locked box was observed on the floor by the living room table; however, the medications were not in the locked box.
Plan of Correction:	1) Executive director has spoken with resident P about keeping medications in a locked box. Resident P verbalized understanding of importance. 2) Designee will audit those residents who self-administer medications to ensure medications are properly stored. A self-administration medication assessment and proper storage of medications audit will be conducted quarterly. 3) The director of health and wellness (DHW) and shift supervisors will be responsible for implementation and monitoring of these preventative measures.