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: April 4, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 3/31/2022. Interviews were conducted with staff and a resident relating to allegations of abuse and staff not documenting an incident in the resident's record. Resident records were also reviewed. Based upon the information gathered during the investigation, the allegation of abuse was "not valid." Based upon the information gathered, however, the allegation of an incident not being documented in the resident's record was 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 #:	22VAC40-73-300-B
Complaint related:	Yes
Description:	Based upon a record review and interviews, the facility failed to ensure a method of written communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings for one of three resident records reviewed. Evidence: 1. On 4/4/2022, the licensing inspector (LI) reviewed the progress notes for resident 1 and there was no documentation regarding an incident which occurred on 3/23/2022 which involved staff 1 and 2. 2. On 4/4/2022, LI interviewed staff 1 who stated she did not document the incident which occurred on 3/23/2022 with resident 1. 3. On 4/4/2022, the LI interviewed collateral 1 and 2 and both stated the incident which occurred on 3/23/2022 was not documented in the resident's progress notes. 4. On 4/7/2022, the LI interviewed staff 2 who stated she did not document the incident which occurred on 3/23/2022.
Plan of Correction:	A late entry was made to the narrative charting in resident record on 4/4/22, to include a description of the incident. Community will ensure that all wellness team members have access to and are utilizing the appropriate documentation tools to communicate significant information between shifts. The executive director (ED), director of health and wellness (DHW) and director of memory care (DMC) review the company policy on narrative charting. An audit will be completed weekly by DHW and/or DMC to ensure that proper forms are being utilized.