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: Aug. 22, 2022 , Aug. 23, 2022 and Aug. 24, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2 GENERAL PROVISIONS 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:

Answered questions and discussed the following topics: 1. Health care oversight, which facility does monthly, must include all residents within a year (one resident record reviewed had not been reviewed for a year). 2. Recommended training record completed in the Relias program be signed by staff at least every six months as there is no electronic signature process in place. 3. Resident council meeting minutes may include the actions taken instead of sending a separate letter ? as long as copies continue to be issued prior to the next meeting. 4. Reviewed the standards for private duty aides and discussed the current process and what needs to be added. 5. Reviewed the sex offender registry standards and explained the process to complete checks prior to admission do not need to be reviewed annually with residents ? only information about the sex offender registry. 6. Ensure a section for corrective actions taken is added to the model fire drill form being used. Note: There were no documented problems noted on any fire drills reviewed. 7. Staff were signing that rounds were completed but need to do so each hour conducted in a timely manner for each resident. 8. Discussed the tuberculin form that was recently sent out to all providers and answered questions.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/22/2022 from approximately 8:55 am to 6:45 pm, 8/23/2022 from approximately 8:15 am to 5:30 pm, 8/24/2022 from approximately 8:20 am to 12:40 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 (including one discharge) + select sections of 6 additional records Number of staff records reviewed: 5 + 9 private sitters + 2 volunteers + select sections of 3 additional staff records Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medication administration, medication cart audits, required postings, memory care and assisted living units and activities. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based upon record reviews and interviews, the facility failed to ensure nine of the nine private duty personnel records reviewed had all required information on file. Evidence: 1. Private duty personnel 1 through 9 had no documentation on file that orientation or training regarding the facilities policies and procedures as related to the private duty personnel were completed. 2. On 8/24/2022, the licensing inspector (LI) interviewed the executive director (ED) and director of health and wellness (DHW) and both stated the facility orientation and training was completed by the agency and not by the facility staff.
Plan of Correction:	All current private duty personnel will complete a documented community orientation. Shift supervisor will conduct, document and ensure that all new private duty personnel are oriented to the policies and procedures related to their duties in the community prior to providing services. ED will ensure orientation is completed and appropriate documentation is kept in the private duty personnel files.
Standard #:	22VAC40-73-450-C
Description:	Based upon documentation and interviews, the facility failed to ensure all assessed needs were included on eight of 10 individualized service plans (ISPs) reviewed. Evidence: 1. The uniform assessment instrument (UAI) (completed 7/13/2022) assessed resident 1 as needing mechanical (MA) and physical assistance (PA) with bathing, toileting, walking and also disorientation to time and place. 2. The ISP (completed 7/13/2022) for resident 1 did not list toileting and walking, MA for bathing and disorientation to time and place. Also, the specific services provided by hospice were not listed. 3. The UAI (completed 5/17/2022) assessed resident 2 as needing MA and PA with walking, abusive/aggressive behaviors, and disorientation to time and place. Resident was also receiving hospice services as of 5/17/2022 and private duty personnel services as of 6/11/2022. 4. The ISP (completed 5/17/2022, for resident 2 did not list walking, abusive/aggressive behaviors, hospice or private duty personnel services. 5. The UAI (completed 7/18/2022) assessed resident 3 as disoriented to time and place all the time. 6. The ISP (completed 7/19/2022) for resident 3 did not include this information. 7. The UAI (completed 7/19/2022) assessed resident 4 as needing MA and PA with dressing and toileting, disruptive behavior and disorientation to time and place at all times. 8. The ISP (completed 7/19/2022) for resident 4 did not list MA with bathing and toileting, disruptive behaviors and disorientation to time and place. 9. The UAI (completed 7/1/2022) assessed resident 5 as needing MA and PA with bathing, dressing, toileting, transferring, stairclimbing and mobility, assistance with wheeling and wound care (as of 7/18/2022). Resident 5 was also assessed as a high risk for falls on 5/12/2022). 10. The ISP (completed 7/1/2022) for resident 5 did not include MA for bathing, dressing, toileting, transferring, stairclimbing and mobility, assistance with wheeling, wound care and fall risk information. 11. The UAI (completed 5/7/2022) assessed resident 6 as needing MA and PA with bathing, dressing, toileting, walking and disorientation to time and date some times. Resident was also assessed as a high risk for falls on 2/17/2022 and was receiving wound care until 6/29/2022. 12. The ISP (completed 5/6/2022, did not include MA for bathing, dressing, toileting and walking, disorientation to time and date, high fall risk and wound care. 13. The UAI (completed 7/13/2022) assessed resident 8 as needing MA and supervision with bathing. Resident was also assessed as a low risk for falls on 7/13/2022. 14. The ISP (completed 7/13/2022) did not include supervision with bathing and fall risk. 15. The UAI (completed 8/1/2022) assessed resident 9 as needing MA with transferring, walking, stairclimbing and mobility; however, these needs were not listed on the ISP (completed 8/1/2022). 16. On 8/23/2022, the LI reviewed the ISPs with the memory care director (MCD) and DHW who reviewed the ISPs and stated these needs were not listed.
Plan of Correction:	An audit of all resident UAIs and ISPs will be conducted to ensure all needs assessed on the UAI are captured on the ISP. HWD will provide all individuals completing UAIs a copy of the UAI manual. ED will ensure prior to all resident signatures that all assessed needs on the UAI are captured in the ISP.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and interviews, the facility failed to ensure one medication for one of five residents was administered as ordered. Evidence: 1. Resident 5 had a physician?s order (signed 7/7/2022) for half 100mg tablet (50mg) Torsemide by mouth daily for edema and a second order (signed 7/7/2022) to take an additional half 100mg tablet (50mg) at 8:00 am as needed if weight is 231 pounds or more. 2. The August 2022 medication administration record (MAR) listed the following weights: 241 8/1; 242 8/2; 237 8/3, 8/6, 8/7; 240 8/8; 235 8/15; 236 8/16; 239 8/18; 237 8/19; 230 8/22. 3. On 8/22/2022, the MAR was initialed that resident 5 received the additional dose of Torsemide; on the remaining dates the resident did not receive the extra dose. 4. On 8/22/2022, the LI interviewed the ED and DHW and both reviewed the MAR and confirmed the medication was not given as ordered. 5. On 8/24/2022, the LI interviewed staff 3, one of the registered medication aides (RMAs) who stated the medication was not given as ordered.
Plan of Correction:	Physician was consulted and the medication order was changed to reflect the appropriate baseline weight for the resident. The physician noted that it was a benefit to the resident that the medication was not received. DHW or designee will review the medication dashboard daily. An in-service will be completed with all parties who administer medications to review the Community Medication Management Plan and proper med pass procedures. This in-service will also highlight how to properly pass medications with vital sign restrictions.
Standard #:	22VAC40-73-860-I
Description:	Director of environmental services will complete an in-service with all housekeeping associates and ensure they understand the importance of storing all cleaning supplies in a locked area. All residents and associates will receive a written notice regarding leaving laundry detergent unattended in the resident laundry areas. A sign will also be posted in each resident laundry area to remind all parties that detergent should not be left unattended in resident laundry areas.
Plan of Correction:	Director of environmental services will complete an in-service with all housekeeping associates and ensure they understand the importance of storing all cleaning supplies in a locked area. All residents and associates will receive a written notice regarding leaving laundry detergent unattended in the resident laundry areas. A sign will also be posted in each resident laundry area to remind all parties that detergent should not be left unattended in resident laundry areas.