VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Harbour View
5871 Harbour View Boulevard
Suffolk, VA 23435
(757) 214-6279

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Jan. 6, 2021 , Jan. 8, 2021 , Jan. 11, 2021 and Jan. 12, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on January 06, 2021 and concluded on January 12, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 52. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, activities calendars, fire drills, fire and health inspections, menus, staff schedules, healthcare, dietary, and pharmacy oversights submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Consultation was provided regarding special care review, staff training hours, activity hours, healthcare oversight, menus, diagnoses, documentation of medication administration, and fall risk ratings.

Violations:

Standard #:	22VAC40-73-1070-B
Description:	Based on record review and discussion, the facility failed to ensure that ordinary materials or objects that may be harmful to a resident with a serious cognitive impairment are inaccessible to the resident except under staff supervision. Evidence: 1. Resident #1?s Individualized Service Plan (ISP) signed on 09/14/2020 documented, ?[Resident #1] needs assistance with wandering and trying to go into other resident?s room??. The need was identified on 02/26/2016. 2. Staff #1 emailed an incident report on 12/18/2020 regarding Resident #1?s ?possible ingestion of sharp object and abrasion to foot?. The report documented date and time of the incident as ?12/18/2020 at 5:30 a.m.? Resident [#1] observed with a piece of lightbulb in [Resident #1?s] hand and broken lightbulb on the floor. Resident [#1] noted with blood around mouth and on right foot. Broken glass noted on floor bathroom ? Removed piece of glass from resident?s [#1] mouth?? 3. Resident #1 was transported to the hospital on 12/18/2020. ?After Visit Summary? dated 12/18/2020 documented, ?Diagnosis: Foreign body ingestion, initial encounter?. 4. Staff #1 stated during discussion that Resident #1 was able to obtain the light bulb from a bathroom trash can in the Special Care Unit.
Plan of Correction:	What Has Been Done to Correct? The Administrator completed and audit of all common areas to include the bathroom in the SCU to ensure all articles were removed. How Will Recurrence Be Prevented? A training was completed with the maintenance team to reiterate safety and the immediate removal of discarded articles. Person Responsible: The Harmony Square Coordinator/Designee
Standard #:	22VAC40-73-680-D
Description:	Based on record review and discussion, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. Evidence: 1. Resident #2?s previous prescriber?s orders dated 06/06/2020 and the current orders 01/05/2021 documented, ?Catapres 0.1mg take one by mouth twice a day for hypertension hold [do not administer] for SBP [systolic blood pressure] less than 160.? 2. Resident #2 October ? December 2020 medication administration records (MAR) documented Catapres 0.1mg was administered 46 times when the SBP was less than 160 during 10/01/2020 and 12/28/2020. The SBP documented on the MAR ranged between 104 and 158. 3. Staff #1 confirmed during discussion the prescriber?s orders and acknowledged that the medication was administered when the SBP was less than 160 and not held per the instructions.
Plan of Correction:	What Has Been Done to Correct? A training was completed with medication staff on following all directives of the physician order. How Will Recurrence Be Prevented? A review of current orders with parameters will be reviewed for compliance. Person Responsible: Healthcare Director/Designee
Standard #:	22VAC40-73-970-E
Description:	Based on record review and discussion, the facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents participating, any special conditions simulated, the time it took to complete the drill, and the weather conditions. Evidence: 1. October 2020, November 2020 and December 2020 fire and emergency evacuation drills did not include the number of residents who participated, any special conditions simulated, time it took to complete the drill, nor weather conditions. 2. Staff #1 acknowledged the aforementioned missing items were not recorded for fire and emergency evacuation drills for said times above.
Plan of Correction:	What Has Been Done to Correct? A review of form with the maintenance director to ensure all blanks are answered on the form. How Will Recurrence Be Prevented? A final review will be completed the form for completion Person Responsible: Executive Director/Designee