VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbor's Edge
One Colley Avenue
Norfolk, VA 23510
(757) 233-0475

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: July 28, 2021

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 22VAC40-90 The Criminal History Record Report

Technical Assistance:

ISP dates were reviewed.

Comments:

A renewal inspection was initiated on 07-28-2021 and concluded on 10-14-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 33. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. One inspector and LA conducted the on-site portion of the inspection on 10-14-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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. A new addition was inspected on 10-14-2021.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Description: Based on resident record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed in writing by an independent physician as having an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #2?s ?Interdisciplinary Notes? dated 01-22-2021 documented the resident transferred to memory support; and ?resident tolerating being in memory support locked unit?? 2. Resident #2?s ?Assessment of Serious Cognitive Impairment? form was signed and dated by an independent physician on 03-31-2021. The form was also checked ?no? documenting the resident is unable to recognize danger and protect his/her own safety and welfare. 3. Staff #1 confirmed resident #2 transferred to the safe, secure unit on 01-22-2021 and could not provide additional documentation of Resident #2 being assessed in writing by an independent physician as having an inability to recognize danger or protect his own safety and welfare prior to admitting to the safe, secure environment on 01-22-2021. 4. Staff #1 acknowledged Resident #2 was placed on the safe, secure environment prior to the resident being assessed in writing by an independent physician.
Plan of Correction:	An audit was conducted for all memory support residents to ensure an assessment was present by an independent physician regarding the need for a safe, secure environment prior to admission. Staff responsible for the admission process was in-serviced regarding paperwork requirements to the memory support unit prior to admission. All new admissions will be audited weekly for a period of 8 weeks to ensure required documents have been completed timely and included in the resident record. The audit results and any trends will be report to the Quality Assurance Committee.
Standard #:	22VAC40-73-860-G
Description:	Description: Based on observation, the facility failed to ensure hot water at taps available to residents are maintained within a range of 105?F to 120?F. Evidence: 1. On 10-14-2021, during an inspection of the facility with Staff #7, the hot water taps sampled were not within the required range in the following areas in the safe, secure environment: Room 419 measured 121.5?F and Room 428 measured 120.5?F. 2. Additionally, a sink located within the new addition in Apartment 323 also was assessed at reaching 122.5?F 3. Staff #1 acknowledged the aforementioned temperatures from the hot water taps in rooms #419, #428, and #323.
Plan of Correction:	Maintenance personnel were immediately notified regarding water temperatures registering out of the appropriate degree range. Water temperatures were adjusted and rechecked by maintenance personnel as well as the Assisted Living Manager and Administrator. All water temperatures were reassessed and found to be in compliance. All residents were assessed and there were no negative outcomes due to the increased water temperatures. Maintenance personnel was in-serviced regarding the appropriate temperature range for the assisted living and memory care unit. Water temperatures will be checked routinely. Any variations will be reported to the Safety Committee.