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 30, 2020 and July 31, 2020

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 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:

1) Carefully review standard 220 to ensure compliance regarding private sitters/companions prior to allowing them to provide service. 2) Ensure uniform assessment instruments (UAIs) are completed prior to admitting a resident and that the information is accurate regarding self-administering medications. Reviewed how to document on the UAI when a resident only self-administers a portion of the medications. 3) Recommended the administrator complete the updated individualized service plan training since it has been a long time since she completed it. Also ensure the specific assistance provided is listed - not just assistance with bathing, etc. 4) Discussed ensuring the medication administration records and physicians' orders be audited on a more frequent basis. 5) Recommended adding a section to the model fire drill form that includes actions taken for problems encountered (there were no noted problems on the ones reviewed) - 970.D. 6) Discontinue the order for TED hose for resident A since home health is now administering leg wraps and the hose are not needed. 7) Staff J must complete the activities training within six months of hire. 8) Recommended adding a statement In the dietary and medication reviews that certifies all requirements in the standard were met.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 7/30/20 and concluded on 7/31/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 83. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident and five staff records. Selected sections of eight additional resident (including one discharge) and five additional staff records were also reviewed. Licenses for the health care oversight nurse and dietitician were reviewed, as well as the records for two private sitters. A virtual tour was conducted as well as a review of the posted menu, activities calendar, first aid/cardiopulmonary resuscitation list, violation notice and residents' rights. The previous violations were checked as well as the rounds log sheets. Additional information was requested in various areas of the standards and was submitted as requested by the administrator and reviewed by this inspector. Information gathered during the inspection determined non-compliance with standards 220.A, 440.A, 450.F, 640.A, 650.B, 660.B, 830.E and 1140.B and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based upon documentation and an interview, the facility failed to ensure five of the nine staff records reviewed completed all required dementia training hours. Evidence: 1) Within the first four months of hire staff E completed seven hours of dementia training; staff J, K, L and M completed nine hours and 15 minutes of training. 2) On 7/30/20, the LI interviewed the ED who stated these were the only training hours the staff completed.
Plan of Correction:	1. Unable to retroactively correct training hours that were not completed within four months of hire. 2. Additional hours to reflect a total of 10 hours of training in cognitive impairment within four moths of start date will be added to our training site for all direct care associates who will be working in our safe and secure environment. 3. The BOM will keep a tickler file of all new direct care staff for four months and review monthly to verify that 10 hours of cognitive impairment training has been completed. 4. Staff E, J, K, L and M have had additional cognitive impairment training added to their assignment. Monitoring will be ongoing.
Standard #:	22VAC40-73-220-A
Description:	Based upon an interview, the facility failed to ensure all information was completed and on file prior to two of two private duty personnel providing care. Evidence: On 7/30/20, the licensing inspector (LI) interviewed the executive director (ED) who stated the facility did not have an agreement on file which included the type and frequency of services to be provided by the private duty aides for resident H. She also stated the facility had not provided orientation and training, verified a tuberculosis screening had been completed or that documentation of the care provided for residents G and H were maintained.
Plan of Correction:	1) A calendar listing the type and frequency of services for resident H has been submitted by the home care organization. The home care organization submitted a letter to this assisted living facility (ALF) verifying that tuberculosis screenings are completed on each private duty personnel prior to entering our ALF, and on an annual basis. The outside agency forms will be initiated for private duty personnel to document care provided during their visits. 2) The executive director (ED) will provide education to the director of health and wellness (DHW), business office manager, (BOM) and home care agencies on required items needed before direct care or companion services can be initiated. 3) To monitor compliance, the ED, DHW, BOM or designee will review with the home care organization, prior to personnel entering our community, the items that are required. Outside agency forms will be reviewed weekly by the DHW, ED or designee. 4) Current private duty personnel will receive orientation, training and education on the outside agency forms by September 4, 2020.
Standard #:	22VAC40-73-440-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of five uniform assessments instruments (UAIs) were completed as required. Evidence: 1) Resident E was admitted on 3/31/20 and the UAI was not completed until 4/2/20. 2) On 7/31/20, the LI interviewed the ED who stated the UAI had not been completed prior to the resident's admission to the facility.
Plan of Correction:	1) Unable to retroactively correct the UAI for resident E. 2) The DHW and director of memory care (DMC) will be educated on the need to complete the UAI prior to a resident moving into our community. 3) The ED will review all new resident paperwork before moving in to verify the UAI has been completed. 4) Education will be provided by September 4, 2020.
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation, the facility failed to ensure five of the five individualized service plans (ISPs) reviewed were updated to include all assessed needs of the residents. Evidence: 1) The ISP (completed 1/19/20 and UAI completed 1/19/20) for resident A did not include mechanical assistance or the type of mechanical assistance needed for bathing, dressing and transferring, physical assistance with mobility, disorientation, mental health services, specific wound care services provided by facility staff and a description of how to ensure safety of resident against falls. 2) The ISP (completed 7/29/20 and UAI completed 7/29/20) for resident B did not include mechanical assistance for bathing and dressing, specific physical assistance needed with eating, disorientation and specific wound care services provided by facility staff. 3) The ISP (completed 4/10/20 and UAI completed 4/9/20) for resident C did not include mechanical assistance for bathing and specific physical assistance needed with toileting. 4) The ISP (completed 3/5/20 and UAI completed 3/4/20) for resident D did not include mechanical assistance for dressing, toileting and walking, the specific type of mechanical assistance needed with transferring, assistance with the independent activities of daily living, assistance with medication administration and disorientation. 5) The ISP (completed 4/2/20 and UAI completed 4/2/20) for resident E did not include mechanical assistance for bathing, toileting, transferring, mechanical assistance and supervision for stairs and mobility, passive wandering and disorientation. This ISP also was not signed by the resident or family member.
Plan of Correction:	1) The ISPs for residents A, B, C, D and E will be updated to include all assessed needs by August 21, 2020. 2) The ED will enroll in the next available updated ISP training along with the DHW to ensure that all needs assessed are documented on the ISP. 3) The ED, DHW or designee will review new resident ISPs to verify that all needs assessed on the UAI have been listed with specific details on the ISP. 4) The ISP training is scheduled for 8/31/2020.
Standard #:	22VAC40-73-640-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of the four July electronic medication administration records (EMARs) were transcribed correctly. Evidence: 1) Resident B had a signed order for Acetaminophen four times a day. The July EMAR listed the order as Acetaminophen three times a day; however, there were four time slots and the medication was documented as being administered four times a day. 2) Resident B had a signed order for wound care that was being provided by home health. The order was for treatment to the heel two times a week and as needed (PRN); however, the July EMAR listed the order as two times a week PRN. 3) On 7/31/20, the LI reviewed these issues with the ED who stated the orders had not been transcribed correctly.
Plan of Correction:	1. The EMAR for resident B has been updated to reflect the current Acetaminophen order. A paper MAR has been generated to reflect current wound care orders and will also be used by the home health agency for documentation. 2. All registered medication aides (RMAs) will be educated on the process for reviewing orders in the EMAR system, which will include the orders to be reviewed also by a licensed nurse. 3. All future orders will be reviewed by a licensed nurse for accuracy. If a RMA reviews orders entered by the pharmacy, they will also be reviewed by a licensed nurse. 4) The education for reviewing orders entered by the pharmacy will be completed by September 4, 2020.
Standard #:	22VAC40-73-650-B
Description:	Based upon documentation, the facility failed to ensure all required information was included in four of the five residents' orders reviewed. Evidence: 1) The following orders did not include a diagnosis: Olanzapine, Oxycodone and Risperidone for resident A; Risperidone for resident E; Melatonin and Risperidone for resident D. 2) The following orders did not include what to do if symptoms persist: Acetaminophen, Greer's Goo, Lorazepam and Oxycodone for resident B.
Plan of Correction:	1) The Risperidone order for resident A has been discontinued. The Olanzapine and Oxycodone orders for resident A have been updated by the provider to include the diagnoses. The Risperidone order for resident E has been updated by provider to include the diagnosis. The Melatonin and Risperidone orders for resident D have been updated to include diagnoses. The Greer's Goo, Lorazepam and Oxycodone orders for resident B have been updated to include directions if symptoms persist. 2. To ensure future compliance, the licensed nurse reviewing orders in the EMAR system will verify that all required information is included in the order. If the order is incomplete, the primary care physician (PCP) will be called or faxed for the additional required information. 3. The ED will request pharmacy reviews to be completed more frequently than every six months for 12 months. The DHW or designee will print physicians' order sheets (POSs) quarterly and review for accurateness and request required information from the provider when needed. 4. The monitoring for this process will be ongoing for compliance.
Standard #:	22VAC40-73-660-B
Description:	Based upon documentation and an interview, the facility failed to ensure one of the three residents who self-administered medications were assessed as capable of doing so. Evidence: 1) On 7/31/20, the LI interviewed the ED who stated resident C was self-administering medications. 2) The UAI completed 4/9/20 indicated resident C required a lay person to administer medications.
Plan of Correction:	1) Resident C is no longer self-administering his medication. 2) Current residents who are self-administering their medications will be assessed quarterly for continued capability. If a current resident is determined to be incapable of self-administration, the medications will be removed from resident's apartment immediately. The resident's primary care provider and responsible party will be immediately notified of the change. 3. The DHW or designee will continue to assess the capabilities of residents who are self-administering medications on a quarterly basis or sooner if needed. The RMAs and licensed nurses will be re-educated on the need to report to the ED, DHW or designee if medications are found in resident apartments who are not assessed as capable of self-administration, or if a decline is noted in a resident who has previously been assessed as capable. 4. Monitoring of this ability will be quarterly or more frequently, if needed, and RMAs and licensed nurses will be educated on this standard by September 4, 2020.
Standard #:	22VAC40-73-830-E
Description:	Based upon documentation and an interview, the facility failed to ensure resident council received a written response regarding actions taken by the facility for resolution of any problems or concerns from the previous meeting. Evidence: 1) The resident council meeting minutes did not include any actions taken by the facility to correct the problems or concerns that were discussed. 2) On 7/30/20, the LI interviewed the ED who stated the facility had not provided a written response to the resident council of facility actions taken to correct any problems or concerns that were discussed in the previous meeting.
Plan of Correction:	1. Unable to retroactively correct resident council meeting minutes that were conducted in January and February 2020. Resident council was suspended starting March 2020 due to COVID-19. 2. Once resident council is restarted, the director of activities (DA) will be conducting the meetings and provide a written response to all recommendations made by council prior to the next meeting. 3. The ED will request a copy of the responses prior to submission to the council by the 20th of each month to review and file in survey preparedness binder with the current month's activity calendars. 4. Monitoring will be completed by the 20th of each month once resident council has been resumed.