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: Jan. 21, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Reviewed the staffing standards for memory care, discussed the current residents needs regarding two person assists and discussed increasing staffing on both the memory care and assisted living units to three staff at a minimum. Administrator will notify the licensing inspector if there is ever a staffing shortage.

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 1/19/2022. Interviews were conducted with residents and staff relating to allegations of insufficient staffing. Staff schedules were also reviewed. The information gathered during the investigation supports the allegation, so the complaint is determined to be valid. 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 #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based upon documentation and an interview, the facility failed to ensure three direct care staff were on duty at all times on the secured unit during the night shift. Evidence: 1. The staff schedule for night shift (10:00 pm to 6:00 am) on the secured unit listed two staff on duty on 1/2/2022 and 1/4/2022 through 1/7/2022; on 1/3/2022 from 12:00 am to 6:00 am; and on 1/13/2022 from 2:30 am to 6:00 am. 2. On 1/21/2022, the licensing inspector interviewed the administrator who stated the resident census from 1/2/2022 through 1/13/2022 was 24 on the secured unit. She also reviewed the schedule and time sheets and stated only two staff were on duty during these dates and times.
Plan of Correction:	The community will ensure that staff to resident ratios meet or exceed this standard so that appropriate supervision and care can be provided to all residents based on the current acuity. The staffing requirements were reviewed with Wellness and Administrative Team. Director of health and wellness or designee will review daily staffing to ensure compliance. In the event that a staff person does not arrive for a scheduled shift, a staff person from previous shift will remain on duty until replacement arrives. The executive director (administrator) will also complete a bi-weekly staffing review report to monitor and to plan ahead for changes in census and acuity.