VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbourway Assisted Living
1217 Alliance Drive
Va beach, VA 23454
(757) 716-2150

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 2, 2021 , Dec. 3, 2021 and Dec. 7, 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 32.1 Reported by persons other than physicians 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted on 12-2-21 (-day 1-ar 8:40 am/dep 4:57 pm and day 2- ar 9:40/ dep 12:25 pm). The census for the day was 65. A tour of the facility was conducted, water temperatures checked, call bells checked, medication observation, resident and staff interviews conducted, first aid kits checked, activity observed, emergency supplied checked and required posting checked for compliance. Comments: A discussion was held regarding the volume of the call bell on the second floor, the category of activities on the December calendar and certification of nutrition, pharmacy and health care oversight reports provided to the administrator. An exit meeting was conducted on 12-2-21, 12-3-21 and 12-7-21 and the acknowledgement form was provided for signature. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days: 12-18-21

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure it followed the blood glucose monitoring practices that are consistent with the CDC recommendations. Evidence: 1. On 12-2-21 during the check of the medication cart on the first floor, with staff #4, residents #5 and #6's glucometers were not labeled. 2. Staff #1, #2 and #4 acknowledged the aforementioned residents' glucometers were not labeled as required.
Plan of Correction:	1. The facility purchased a dremel tool and engraved each glucometer with the resident's name. This is to ensure the machine remains labeled even after the routine disinfecting, which was causing previous labels to come off the devices 2. The Unit Manager, or designee will ensure all devices are labeled when a new residents moves in, a new order is obtained, or a new device comes into the facility.
Standard #:	22VAC40-73-210-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when adults with mental impairments resident in the facility, at least four of the required hours shall focus on topic related to residents? mental impairments. Evidence: 1. On 12-2-21 staff #4?s training record documented 2.75 hours of mental impairment training. Staff?s record did not have documentation of the required 4 hours of mental impairment training. 2. Staff #2 acknowledged staff #4 did not have the required hours of mental impairment training.
Plan of Correction:	1. In order to ensure all staff have the required training hours, All staff shall be assigned one hour of training pertaining to residents with mental impairments in Relias that will need to be completed every other month
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR was posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date. Evidence: 1. On 12-21-21 during the tour of the facility, the request was made to see the first aid and CPR posting of all staff. The facility did not have a posting of staff certification in first aide CPR or both. 2. Staff #1 and #2 acknowledged the facility did not have the list of staff certified in first aide or CPR or both posted in the facility.
Plan of Correction:	1. The staff posting of CPR/First Aid was done during the inspection. 2. Human Resources shall send the updated listing of all staff with CPR/First Aid when an update occurs to the Harbourway Management team. The Unit Manager, or designee shall update the posting.
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to maintain a written work scheduled that included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. The October, November and December activities staff scheduled provided during the inspection listed first name only of staff scheduled. 2. On 12-3-21, the inspector showed the dietary schedule to staff #1 who acknowledged the document did not include all required information.
Plan of Correction:	1. Activity staff have updated their schedule to include both first and last names. 2. The whole name of all staff will be placed on the schedule each month prior to the schedule being posted
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility did not have the posting of the name of the current on-site person in charge, as required per the regulation, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 12-2-21, during a tour of the facility, the inspector requested to see the posting of the staff person in charge as it was not visible at the main entrance of the facility where the license, resident?s rights and last inspection were posted in a conspicuous place to the residents and the public. 2. The staff in charge information was the staff weekly schedule located in a binder near the staff?s time clock. The binder was labeled ?TEAM- Orientation-Welcome?.
Plan of Correction:	1. The facility designates the nurse or med aide for each floor as the staff person in charge when the Administrator, Assistant Administrator, or Unit Manager are not on the property. During the inspection, the schedule book was removed and replaced with a display document holder that had just arrived from being previously purchased. This display holder is in a centrally located public area. 2. The facility posted, by each main entrance, a sign that contains the phone numbers of the leadership team. It also contains a statement regarding the Staff Member on Duty that states "The Nurse/Med Aide assigned to each floor will serve as the staff member on duty when administration is not in the facility. The phone numbers of each unit are listed below. The name of the staff person assigned for each shift is located on the table across from the garden entrance."
Standard #:	22VAC40-73-580-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: 1. During the monitoring inspection, a request was made for the facility's annual health inspection. The document provided was dated 1-30-20. 2. Staff #! and #2 acknowledged not having any other inspection.
Plan of Correction:	1. The Food and Beverage Manager contacted the health department to schedule an inspection. All attempts to contact the Health Department shall be recorded. The F&B Manager, or designee shall continue to make contact until such time the inspection occurs 2. The F&B Manager, or designee shall contact the Health Department each year to ensure the annual inspection falls within the annual timeline. Documentation of all contact shall be on file.
Standard #:	22VAC40-73-940-A
Description:	Based on staff interviewed, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: 1. On 12-2-21 during the monitoring inspection, a request was made for the last fire inspection. The last inspection documented on the inspector's request form was dated 9-30-19. 2. Staff #1 and #2 acknowledged the facility did not have a current fire inspection.
Plan of Correction:	1. The facility was awaiting a response from the fire department on the assignment of a new fire marshall to come out and inspect the facility. The new fire marshall was assigned to come out on 12/9/21 to complete the insepction. 2. Inspection was completed on 12/9/21 3. Security Director, or designee shall contact the fire marshall each year and document to ensure an inspection is completed in a timely manner
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit in the assisted living facility included all required items and items with expiration dates did not have dates that have already passed. Evidence: 1. On 12-2-21, the first aid kit on the first floor was checked with staff #2. One hand sanitizer was dated 2019 and the other was dated May 2021. The checklist did not include dates of items with expiration dates. 2. Staff #4 confirmed the date for the hand sanitizer dated in 2019. 3. Staff #2 acknowledged the items in the first aid kit were expired.
Plan of Correction:	1. All expired items in the first aid kit were replaced during the inspection 2.The expiration date on the checklist has been added back onto the form. 3. The Unit Manager, or designee shall conduct a training with all Nurses/Med Aides on how to complete the first aid kit inspection, the items that must be in the kit, and the importance of removing any expired items prior to the date and replacing.
Standard #:	22VAC40-73-980-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the motor vehicle used to transport residents had all of the required items. Evidence: 1. On 12-2-21 a check of the first aid kit that transport residents was conducted with staff #2 and #10. The kit did not have a disposable single-use breathing barrier or shields for use with rescue breathing or CPR or CPR mask or other type. The kit also did not have extra batteries for the flashlight. 2. Staff #2 and #10 acknowledged the CPR mask and extra batteries were not in the first kit on the vehicle.
Plan of Correction:	1. All missing items were replaced before the end of the inspection on the Atlantic Shores vehicles. 2. The Director of Resident Services was given the First Aid Kit checklist and will be instructing all drivers on how to complete the check to ensure all items are in the first aid kit and have not expired