VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Oakbrooke
301 Clearfield Avenue
Chesapeake, VA 23320
(757) 315-6900

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Oct. 31, 2019 and Nov. 1, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

An unannounced renewal inspection was conducted by two Licensing Inspectors from the Eastern Regional Office on 10/31/2019 from 9:46 AM to 4:26 PM and on 11/01/2019 from 8:35 AM to 4:43 PM. There were 75 residents in care at the time of the inspection. A tour of the facility was conducted, water temperatures were sampled, and the emergency food and water were observed. Water temperatures were noted to be within the required range. LI observed a medication pass observation on the Assisted Living Unit and Special Care Unit. 10 resident records and 5 staff records were reviewed. LI observed lunch and an activity during the inspection. Interviews were conducted with staff, residents, and family members on site. The following documents were reviewed: Health care oversight, Resident Council, Fire and Emergency Evacuation Drills, Emergency Preparedness plan, Menus, Activity Calendars, and the Dietitian reports. The facility First Aid kit and the First Aid kit located on the van was also reviewed. The following was discussed with the Executive Director and the Health Care Coordinator: UAI's and ISP's (?Date identified? on ISP should remain the same with each ISP update), documentation regarding physician's orders and treatments, documentation of the MARs, health care oversight dates (quarter reviewed dates), dietary oversight to include all requirements, staff schedules regarding the staff person in charge. The facility received violations "under" Personnel, Admission, Retention, and Discharge of Residents, and Resident Care and Related Services. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the Violation Notice within 10 days of today's date, 12-11-2019. The provider's responses for the "plan of correction" was not received as of 12-16-2019 and will not appear on this Violation Notice.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the physical examination was completed within 30 days of admission. Evidence: 1.During resident #10?s record review with staff #1, the resident admitted to the facility on 08-26-2019.The physical examination was dated 07-08-2019, and was not completed within 30 days of admission. 2. During interview, staff #1 acknowledged resident #10?s physical examination was not completed within 30 days of admission.
Plan of Correction:	The Executive Director will review the history and physical prior to admission and ensure the date of physical meet the regulatory requirement.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facil- ity failed to ensure the individualized service plan (ISP) included a description of the resi- dent?s identified needs based upon the Uniform Assessment Instrument (UAI). Evidence: 1. On 10-31-2019 and 11-01-2019, during resident record review with staff #1 and staff #2, the following ISP?s did not include a description of the resident?s identified needs: A.Resident #3?s UAI dated 10-27-2019 documented the resident needs mechanical assistance only with mobility, mechanical and physical assistance with bathing, supervision with toileting, mechanical assistance and supervision with walking, and bladder incontinence less than weekly.The most current ISP on file dated 10-28-2019 did not include a description of the resident?s need for mobility; the type of mechanical device needed for bathing; or how the staff will supervise the resident with walking. The ISP also documented the resident was continent of bladder and independent with toileting; and did not document the resident?s identified need for supervision or the bladder incontinence as documented on the UAI. B.Resident #5?s UAI dated 08-25-2019 documented the resident needs mechanical help with mobility; however, the current ISP on file dated 08-25-2019 did not include a description of the resident?s identified need for mobility. C.Resident # 10?s UAI dated 09-25-2019 documented the resident has abusive/aggressive/disruptive behaviors less than weekly; with inappropriate behavior to include ?pushing, hitting and use of profound words.? The current ISP on file dated 09-25-2019, did not include a description of the resident?s identified behaviors as documented on the UAI. 2. During interview on 10-31-2019 and 11-01-2019, staff #1 acknowledged the aforementioned ISP?s did not include a description of the resident?s identified needs based upon the UAI.
Plan of Correction:	Facility updated the UAI/ISP of Resident #3. Health Care Director/Designee will complete the ISP based on the findings of the UAI. ED/Designee will review UAI and ISP to confirm information is documented correctly.
Standard #:	22VAC40-73-510-A
Description:	Based on record review and interview, the facility failed to ensure for each resident requiring mental health services, the services of a qualified health care professional should be secured as appropriate based on the resident's current evaluation and to the extent possible, the resident's preference for service provider.The assisted living facility should assist the resident in obtaining the services. If the services are not able to be secured, the facility should document the reason for such and the efforts made to obtain the services. If the resident has a legal representative, the representative should be notified of failure to obtain services and the notification should be documented. Evidence: 1. On 10-31-2019, during resident #2?s record review with staff #1 and staff #2, a signed physician?s note dated 10-01-2019 documented ?patient did state [resident] wanted to see a neurologist it was about pins and needles sensation in the dorsum of [resident?s] scalp? I talked to [resident] for probably 40 minutes and when we got down to it what [resident?s] mainly upset about is that [resident?s] lived in our house since 2005 with [resident?s] husband and the family took her out of the house and put [resident] into harmony in April. [Resident] admits that that?s been very distressful to [resident]? when we got to talking about the stresses of moving here [resident] readily admitted that that was a major problem with [resident]?. Also has a record of chronic depression? [Resident] gave me a few examples including whether [family] took [resident] to have a pedicure and manicure and told [resident] ?[resident] you?re dying.? The patient stated ?it?s such a strain my [family] pick me up and threw me away?? Physical exam: lying in bed... [resident?s] alert and oriented times three looks depressed and slightly anxious or worried? I think all this is psychological? I spoke with staff #2 the nurse manager about trying to get a counselor to talk with the patient? This seems a situational problem due to her forced move.? When asked if the facility assisted resident #2 in obtaining counseling services, staff #2 stated ?no, the services were not scheduled.? There was no documentation on file to verify the facility assisted the resident in obtaining counseling services from a qualified health care professional based on the resident's current note from the physician. 2. On 10-31-2019, upon further review of resident #2?s record, staff #2 could not locate and/or provide documentation on file of any efforts the facility made in obtaining the counseling services or the reason the services were not secured. Additionally, there was no documentation on file to verify that the facility notified the legal representative of the facility?s failure to obtain counseling services. 3. During interview on 10-31-2019, staff #1 and staff #2 acknowledged that the facility did not assist resident #2 in obtaining counseling services based on the note from the physician on 10-01-2019.Staff #1 and staff #2 also acknowledged there was no documentation on file of the reason why the counseling services were not secured; or that the legal representative was notified of the facility?s failure to obtain the services.
Plan of Correction:	The facility received a discontinue order for Resident #2 services. Executive Director/Designee will ensure the scheduling of physician orders requiring the assistance of a mental health professional.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, record review, and inter- view, the facility failed to ensure menus for meals and snacks for the current week are dated and posted. Evidence: 1. On 11-01-2019 during the lunch observation, the menus for meals and snacks were not posted on the Assisted Living Unit and Special Care Unit.Staff #9 acknowledged that the menus for meals and snacks were not posted on either unit. 2. Staff #9 provided a copy of the September and October 2019 weekly menus. During review of the weekly menus with staff #1 and staff #9, the following dates were missing from the menus and did not include the meal for breakfast: A.September 2019: Week 1 (09/01 ? 09/07); Week 2 (09/08 ? 09/14); Week 3 (09/15 ? 09/21); and Week 4 (09/22 ? 09/28) were not dated. Week 1 (09/29 ? 10/05) did not include the meal for breakfast. B. October 2019: Week 2 (10/06 ? 10/12); Week 3 (10/13 ? 10/19); Week 4 (10/20 ? 10/26) were not dated and did not include the meal for breakfast. 3. During interview on 11-01-2019, staff #1 and staff #9 acknowledged the aforementioned weekly menus were not dated and did not include the meal for breakfast.
Plan of Correction:	The facility posted weekly menu during inspection. The Dining Services Director/Designee will ensure that all menus for meals and snacks will be posted where the resident can review. Dates shall be on all paperwork.
Standard #:	22VAC40-73-620-B
Description:	Based on record review and interview, the facility failed to ensure the oversight of special diets included a review of the physician's or other prescriber's order and the preparation and delivery of the special diet, and an evaluation of the adequacy of the resident's special diet and the resident's acceptance of the diet. Evidence: 1. On 11-01-2019, a list was observed in the kitchen which documented 11 residents receive a special diet consisting of nectar thickened liquids, mechanical soft, and pureed food. When asked to review the facility?s oversight of special diets, staff #1 provided a copy of the facility?s oversight of special diets dated 06-20-2019 and 09-27-2019.The oversights did not include a review of the physician's or other prescriber's order and the preparation and delivery of the special diet, or an evaluation of the adequacy of the resident's special diet and the resident's acceptance of the diet. 2. During interview on 11-01-2019, staff #1 acknowledged the oversight of special diets dated 06-20-2019 and 09-27-2019 did not contain the required information.
Plan of Correction:	Executive Director/Designee will ensure that the Dietician?s Oversight of Special Diets will include all regulatory requirements; physicians order (preparation and delivery of the special diet), identification of the resident and date of the oversight, recommendations will be reported to physician, actions taken in response to report will be documented in the resident?s record.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, record review, and inter- view, the facility failed implement the written plan for medication management to ensure that each resident's prescription medicationsand any over-the-counter drugs and supplements ordered for the resident are refilled in a timely manner to avoid missed dosages. Evidence: 1. On 10-31-2019 during the medication pass observation on the third floor at approximately 9:01 AM, staff #5 was unable to locate resident #5?s HC/Lido Aloe Suppository on the medication cart or in the refrigerator located near the nurse?s station. Resident #5 did not receive the scheduled HC/Lido Aloe Suppository; however, staff #5 documented the MAR that the medication was administered. 2. On 10-31-2019, during resident #5?s record review with staff #1 and staff #2, the October 2019 Medication Administration Record (MAR) documented the resident did not receive the HC/Lido Aloe Suppository during the 9:00 AM administration time on 10-23-19, 10-25-2019, 10-26-2019, 10-28-2019, and 10-29-2019; and during the 9:00 PM administration time on 10-21-2019 through 10-23-2019, 10-26-2019,10-27-2019, 10-28-2019, 10-29-2019, and 10-31-2019. 3. On 10-31-2019, staff #1 provided a copy of the facility?s written plan for medication management which documented ?Nurses and RMA?s shall be responsible for the timely ordering, and ere-ordering of medications so that there are no missed doses or interruptions in the medications being administered.? ?If a resident wishes to use an outside pharmacy? The pharmacy must have the ability to provide 24 hour a day, 7 day a week service including delivery of the medication within 24 hours or receipt of the Rx and/or so that the next scheduled dose of a medication is not missed when dosages change.? 4. During interview on 10-31-2019, staff #1 and staff #2 acknowledged resident #5?s HC/Lido Aloe Suppository was not available on the cart for administration and that the medication was not refilled in a timely manner to avoid missed dosages.
Plan of Correction:	Facility ordered and received Resident # 5 suppository. Health Care Director/Designee will confirm that all medications are ordered and available.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. During resident #8?s record review with staff #1 and staff #3, the current physician?s order dated 08-16-2019 documented ?sliding scale Novolog?. Documentation attached to the physician?s order form provided instructions for the amount of insulin to be administered for blood sugars as followed: for a blood glucose reading greater than 400, ?administer 12 units subcut, notify provider, and repeat blood sugar check in 30 minutes.? The September 2019 MAR documented the resident?s blood sugar was 432 on 09-15-2019 at 12:00 PM; however, the MAR did not include documentation that resident?s physician was notified or that the resident?s blood sugar was rechecked in 30 minutes per the physician?s instructions. Staff #3 could not locate and/or provide documentation to verify the physician was contacted regarding the resident?s blood sugar or that the blood sugar was rechecked in 30 minutes. 2. During interview on 10-31-2019, staff #1 and staff #3 acknowledged resident #8?s physician?s instructions and September 2019 MAR did not provide verification that the resident?s repeat blood sugar was checked in 30 minutes per the physician?s instructions.
Plan of Correction:	Facility received physician documentation of verbal orders for Resident #8. The Healthcare Director/Designee will ensure all orders are documented and transcribed to the Medication Administration Record.
Standard #:	22VAC40-73-700-2
Description:	Based on observation and interview, the facility failed to post "NoSmoking-Oxygen in Use" signs in any room of a building where oxygen is in use. Evidence: 1. On 10-31-2019, during the tour of the facility with staff #4, resident #1 (Room 229) and resident #8 (Room H117) were observed using oxygen; however, ?No Smoking-Oxygen in Use? signs were not posted in or outside of the residents rooms. 2. During interview on 10-31-2019, staff #4 acknowledged the facility did not post "No Smoking-Oxygen in Use" signs in or outside of the aforementioned rooms where oxygen was in use.
Plan of Correction:	The facility placed no smoking signs on the door of Resident # 1 & 8. The Health Care Director/Designee will confirm that when a resident is placed on oxygen therapy that the appropriate signage is posted.