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 31, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/31/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on regarding allegations in the areas use of chemical restraints, abusiveness toward a specific resident, failure to properly screen staff. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed an observation of of the memory care unit. Number of resident records reviewed/interviewed: 1 Number of staff records reviewed/interviewed: 6 plus/5 Observations by licensing inspector: Residents in memory care were engaged. There were no outward signs of oversedation. Further review of all medication administration records showed no documentation of overuse of medication and very little if any of PRN medication beyond Tylenol. The cart showed no signs of medication misuse. Additional Comments/Discussion: The resident named in the complaint who allegedly was verbally abused by a staff person said, during her private interview, that no such thing occurred. She further indicated she was the one who was loud and instigated the interaction to which the staff remained calm throughout. She said she later apologized to both that staff ember and the administrator for creating a scene in common space. As for screening staff the facility does what is required in the standards and an unscheduled drug screen before hiring. This licensing inspector does not have the expertise to determine if their screening tool is adequate but questions to law enforcement indicate it is a tool often used and appears effective when it is an unscheduled screening. The complainant did not include contact information to obtain a specific individual they felt were being chemically restrained or specific staff that potentially should have an alternative drug tests and the justification for that allegation. Without that additional information the allegations regarding chemical restraints or insufficient staff screening could not be substantiated. The allegation of verbal abuse by a staff member toward a resident was found invalid based on the resident?s interview. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can be found on the violation notice. 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. 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 Sharae Henderson, Licensing Administrator at (804) 726-7833 or by email at sharae.henderson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of medication administration records for all residents residing in the memory care unit, the staff did not consistently indicate what their response was to the resident when the "as needed" medication was noted to not be effective.
Plan of Correction:	An in-service will be completed by 8/31 with all individuals currently registered to administer medications on the proper procedure for documentation of unsuccessful results, following administration of a PRN medication. All PRN medications administered will be reviewed by DHW/DMC each morning. An in-service will be completed by 8/31 with all individuals currently registered to administer medications on the proper procedure for documentation of unsuccessful results, following administration of a PRN medication. All PRN medications administered will be reviewed by DHW/DMC each morning. Responsibility is further assumed by them for maintaining compliance.