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: Dec. 17, 2021 and Dec. 20, 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 63.2 Facilities and Programs.. 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 renewal inspection was conducted on 12-17-21 and 12-20-21. The facility census was 81. The administrator was present on both days of the inspection. A medication observation was conducted, staff and resident record reviews conducted, breakfast meal observed on the assisted living and safe, secure unit, first aid kit for facility and vehicles were conducted, resident and staff interviews conducted, emergency supplies reviewed, call bell observed, water temperature conducted and activity on safe, secure unit observed. Violations and technical assistance provided throughout the inspection. An exit interview with the administrator was conducted on both days and the Acknowledgement form was signed by the administrator. 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 1-7-2022

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within four months of starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairments that meets the requirements of subsection 22VAC40-73-1140-C of the regulation. Evidence: 1. On 12-20-21 during record review with staff #1 and #2, the following staff?s record did not have documentation of 10 hours of cognitive impairment training within the four months of employment: (a) staff #11, no documentation of dementia training following employment, date of hire 8-11-21 and (b) staff #12, documented 6.0 hours of training, date of hire 4-7-21. 2. Staff #1 and #2 acknowledged the aforementioned staff?s record did not document required hours of cognitive training.
Plan of Correction:	What Has Been Done to Correct? Administrator/Designee will ensure within four months of starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairments. How Will Recurrence Be Prevented? Business Office Manager/Designee will create a new hire checklist to include (10) hours of cognitive impairment training. As staff complete, document will be checked-off by both Business Office Manager/Designee and Administrator/Designee. Person Responsible: Business Office Manager/Designee, and/or Healthcare Director/Designee, and/or Administrator/Designee Due Date: 01/14/22
Standard #:	22VAC40-73-1140-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within the first month of employment, staff, other that the administrator and direct care staff, who will have contact with residents in the special care unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia. Evidence: 1. On 12-20-21, during record review with staff #1 and #2, the following non-nursing staff did not have 2 hours of cognitive impairment training within the first month of employment: (a) staff #8, date of hire 10-14-21; staff #10, date of hire 11-10-21 and (c) staff #13, date of hire 1-28-21. 2. Staff #1 and #2 acknowledged the aforementioned staff did not complete 2 hours of cognitive training within the first month of employment.
Plan of Correction:	What Has Been Done to Correct? Administrator/Designee will ensure within the first month of employment, non-direct care staff, who will have contact with residents in the special care, unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia How Will Recurrence Be Prevented? Business Office Manager/Designee will create a new hire checklist to include (2) hours of dementia training for all non-direct care staff. As staff complete, document will be checked-off by both Business Office Manager/Designee and Administrator/Designee. Person Responsible: Business Office Manager/Designee, and/or Healthcare Director/Designee, and/or Administrator/Designee Due Date: 01/14/22
Standard #:	22VAC40-73-100-C-1
Description:	Based on observation and staff interviewed, the facility failed to ensure infection control procedures were implemented. Evidence: 1. On 12-17-21 during the medication observation check of the medication cart on the second floor with staff #3, the following residents? glucometer were not labeled: (a) resident #11, (b) resident #12 and (c) resident #13. 2. During initial exit meeting on 12-17-21 and final on 12-20-21, staff #1 acknowledged the aforementioned residents? glucometers were not labeled.
Plan of Correction:	What Has Been Done to Correct? Residents #11, #12, and #13 ? each resident?s glucometer machine are labeled with their name on the machine. How Will Recurrence Be Prevented? Upon admission and/or new order, all resident?s glucometer machines will have their name labeled on machine. An alert file will be maintained to ensure all machines are labeled. Person Responsible: Healthcare Director/Designee Due Date: 01/04/22
Standard #:	22VAC40-73-250-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the facility had verification that the staff person had received a copy of his current job description . Evidence: 1. On 12-20-21, staff #8`s record did not have documentation of having received a copy of his/her job description. 2. Staff #1 acknowledged the aforementioned record did not have documentation of receiving a copy of the job description.
Plan of Correction:	What Has Been Done to Correct? Staff #8 has signed a job description. How Will Recurrence Be Prevented? Business Office Manager/Designee will create a new hire checklist to include job description and will check-off as completed for each new staff member?s personnel file. Administrator/Designee will second check each new staff member?s checklist. Person Responsible: Business Office Manager/Designee and Administrator/Designee Due Date: 01/12/22
Standard #:	22VAC40-73-250-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 12-20-21 a review of staff records with staff #1 and #2, the following staff?s record did not have documentation of the absence of tuberculosis (TB) in a communicable form: (a) staff #8, date of hire documented as 10-14-21; (b) staff #9, date of hire documented as 6-2-21 and (c) staff #10, date of hire documented as 11-10-21. 2. Staff #1 and #2 acknowledged the aforementioned staffs? record did not included documentation of the absence of TB.
Plan of Correction:	What Has Been Done to Correct? Staff members #8, #9, and #10 obtained a TB screening. An audit of the TB risk assessments will be completed for all new hires. How Will Recurrence Be Prevented? Upon hire, all new staff members will present a risk assessment. Business Office Manager/Designee will create a new hire checklist to include check-off box for completed TB screening ? this checklist will be located in each new staff?s personnel file. Administrator/Designee will be the second checker. Person Responsible: Business Office Manager/ Designee and Administrator/Designee Due Date: 01/04/22; audit completion: 01/14/22
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid and CPR listing posted was kept up to date. Evidence: 1. The first aid/CPR posting on the second floor and provided for review included dates that were past due for CPR/FA. The list also did not include the names of all staff members. 2. On 12-17-21 during exit meeting staff #1 and #2 acknowledged the first aid/ CPR posted document was not kept updated.
Plan of Correction:	.What Has Been Done to Correct? All staff required to have first aid and CPR, will be listed and posted ? current posting is up to date. How Will Recurrence Be Prevented? An alert file will be maintained to ensure all appropriate staff are listed and up to date on the first aid and CPR posting. Person Responsible: Business Office Manager/Designee Due Date: 01/12/22
Standard #:	22VAC40-73-290-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the written work schedule 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. On 12-20-21 a review of the written work scheduled with staff #1 and 2, the nursing staff schedule for December 2021 did not indicate whomever is in charge at any given time. The December 2021?Life Enrichment Employee Schedule? documented staff?s first name only, the sales person schedule did not include job classification and documented staff?s first name only, the December schedule for dietary department documented staff?s first name only and staff job classification was not documented for staff who are servers and the housekeeping schedule for staff #14 and #17 documented first name only. 2. Staff #1 acknowledged the aforementioned staff schedules did not contain all required information.
Plan of Correction:	What Has Been Done to Correct? All staff work schedules include staff member?s full name and job classification. Staff member in-charge is posted at the front lobby desk, main 2nd floor nurse?s station, and on the direct care daily assignment sheets. How Will Recurrence Be Prevented? Each department manager/designee will create department staff schedule using the appropriate guidelines. Administrator/Designee will second check each department schedule and maintain file. Person Responsible: Each Department Manager/Designee Due Date: 01/01/22
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge, as provided for in the regulation, in a place in the facility that is conspicuous to the residents and to the public. Evidence: 1. On 12-172-1 upon entering the facility, the posting for the staff person in charge (SIC) was not available. The inspector inquired of staff #14 and #15 who was the staff person in charge. Neither staff was able to provide the information. The inspector went to the second floor and spoke with staff #16. The staff provided a copy of the posted staff assignment sheet which noted the first name of the staff in charge per shift. 2. Staff #1 acknowledged the staff person in charge posting was not available when the inspector arrive at 8:45 a.m. on 12-16-21. The staff sheet is not posted in an area conspicuous to the residents and to the public.
Plan of Correction:	What Has Been Done to Correct? Staff member in charge, all three shifts, is posted at the front lobby desk, main 2nd floor nurse?s station, and on the direct care daily assignment sheets. How Will Recurrence Be Prevented? Healthcare Director/Designee will create daily staff member in-charge posting, using the appropriate guidelines. Administrator/Designee will second check and maintain schedule file. Person Responsible: Healthcare Director/Designee and Administrator/Designee Due Date: 01/01/22
Standard #:	22VAC40-73-320-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 12-20-21, during record review with staff #2, resident #8?s record did not include documentation on an annual TB. The last documented TB was dated 10-1-20; resident was admit date documented as 2-28-20. 2. Staff #2 acknowledged the aforementioned resident?s TB was last dated 10-1-20.
Plan of Correction:	What Has Been Done to Correct? Resident #8, an up to date TB screening has been obtained. How Will Recurrence Be Prevented? Upon annual assessment, all residents will obtain a TB screening. An audit of the TB risk assessments will be completed for all existing residents. An alert file will be maintained to ensure annual TB screenings are completed. Person Responsible: Healthcare Director/Designee Due Date: 01/04/22; audit completion: 01/14/22
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the Uniformed Assessment Instrument (UAI), was used to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 12-17-21, review of resident #3?s record with staff #1, the resident?s UAI was last completed on 10-12-20. 2. Staff #2 acknowledged the UAI for resident #3 was not updated and not current.
Plan of Correction:	What Has Been Done to Correct? Resident #3 ? UAI has been updated. How Will Recurrence Be Prevented? Upon annual reassessment, UAI?s will be updated to identify needs of residents. An alert file will be maintained to ensure annual assessments and/or significant changes that occur are noted and updated on UAI. Person Responsible: Healthcare Director/Designee Due Date: 01/04/22
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure all assessed needs were addressed on the resident?s individualized service plan (ISP). Evidence: 1. Resident #1?s record documented on 8-11-21 resident is prescribed Oxygen. This assessed need is not documented on the residents 6-4-21 ISP. 2. Resident #8?s ISP dated 3-30-31 did not include wound care services documented in the hospice care plan. A review of care plans in the record document wound care services dated as of 6-25-21. 3. Resident #10?s record documented in the hospice care plan resident?s hearing loss. Staff #2 acknowledged staff needed to speak louder and face resident when having a conversation. This information is not documented on the ISP dated 1-15-21. 4. Staff #2 acknowledged the aforementioned residents? ISPs did not document all assessed needs.
Plan of Correction:	What Has Been Done to Correct? Residents #1, #8, and #10 ? ISP?s has been updated. How Will Recurrence Be Prevented? Upon completion of UAI?s for residents, ISP?s will be created that identify needs of residents as indicated on UAI. An alert file will be maintained to ensure annual assessments and/or significant changes that occur are noted and updated on ISP?s. Person Responsible: Healthcare Director/Designee Due Date: 01/10/22
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: 1. On 12-17-21, resident #3?s ISP was last reviewed and updated on 11-16-20. Staff #2 acknowledged resident?s ISP was not updated at least annually. 2. Resident #4?s ISP dated 5-19-21 was not updated to reflect the resident?s change in condition and outcome for therapy services which ended on 6-11-21. 3. Staff #2 acknowledged the aforementioned residents? IPS? were not updated to reflect the residents? current status.
Plan of Correction:	What Has Been Done to Correct? Residents #3 and #4 ? ISP?s has been updated. How Will Recurrence Be Prevented? Upon completion of UAI?s for residents, ISP?s will be created that identify needs of residents as indicated on UAI. An alert file will be maintained to ensure annual assessments and/or significant changes that occur are noted and updated on ISP?s. Person Responsible: Healthcare Director/Designee Due Date: 01/07/22
Standard #:	22VAC40-73-680-K
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN medication, the order from the resident?s physician or other prescriber shall include the exact dosage. Evidence: 1. On 12-17-21, resident #1?s record included an order for Oxygen to be administered, the 8-11-21 document noted Oxygen 2-4 Liter continuous as needed. Staff was asked if the resident was to received Oxygen as needed or continuously. 2. Staff #2 acknowledged the order was not clearly written.
Plan of Correction:	What Has Been Done to Correct? Training completed with medication administration staff to know when to question if MD orders need to be clarified. A copy of the medication policy is also on the med carts. How Will Recurrence Be Prevented? A review of current orders with parameters will be reviewed for compliance. In addition, a med pass review will be conducted with each medication administration staff member. Person Responsible: Healthcare Director/ Designee Due Date: 01/12/22
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees Fahrenheit (F). Evidence: 1. On 12-17-21 during a tour of the facility with staff #6, the water temperature in the facility?s Sweet Memories (safe, secure unit) in room #H-121 was 125.8 degrees F. 2. Staff #1 and #6 acknowledged the water temperatures were not maintained within a range of 105 degrees to 120 degrees Fahrenheit.
Plan of Correction:	What Has Been Done to Correct? Maintenance Director/Designee will make rounds and check water temperatures in resident?s units to ensure water temperatures are at the appropriate temperature. How Will Recurrence Be Prevented? An alert file will be maintained to ensure monitoring of water temperatures are accurate in resident?s units. Person Responsible: Maintenance Director/Designee Due Date: 01/07/22
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the building was maintained in good repair and kept clean. Evidence: 1. On 12-17-21 during a tour of the dining area on the first floor, the vent on the wall near where resident #4?s table is located was observed covered with grayish colored substance. 2. Staff #2 acknowledged the vent was covered with a greyish colored substance and in need of cleaning.
Plan of Correction:	What Has Been Done to Correct? Housekeeping staff dusted and cleaned the dining room vent. How Will Recurrence Be Prevented? An alert file will be maintained to ensure weekly monitoring of housekeeping cleaning task are completed. Person Responsible: Maintenance Director/Designee Due Date: 01/04/22
Standard #:	22VAC40-73-940-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13 VAC 5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. On 12-17-21, a request for the facility?s fire inspection was conducted. The date of the last inspection was dated 1-29-19. 2. On 12-20-21, the emails attached to the fire drill did not address the fire inspection, all emails were related to suspension of fire drills with staff and resident. Staff #1 was informed that the documentation did not address the facility?s fire inspection.
Plan of Correction:	What Has Been Done to Correct? Maintenance Director has scheduled annual fire inspection with local Fire Marshall. How Will Recurrence Be Prevented? An alert file will be maintained to ensure annual fire inspections with the local Fire Marshall are completed. Person Responsible: Maintenance Director/Designee Due Date: 01/06/22
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interview, the facility failed to ensure the fire and emergency evacuation drawing posted contained all required information. Evidence: 1. On 12-17-21 during a tour of the facility with staff #6, the evacuation posting on the first floor in the dining area and the first floor in hallway near concierge and administrator?s office and the posting on the second floor near the elevator did not include the telephone locations, fire alarm boxes and fire extinguishers 2. On 12-17-21 during the exit interview, staff #1 acknowledged the posted emergency evacuation drawings did not include all required information.
Plan of Correction:	What Has Been Done to Correct? The Maintenance Director/Designee will update all floor plan/drawings to reflect the missing information. How Will Recurrence Be Prevented? Maintenance Director/Designee will make building rounds and check to ensure all floor plans/drawings are reviewed for accuracy. Person Responsible: Maintenance Director/Designee Due Date: 01/14/22
Standard #:	22VAC40-73-970-E
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the record of the required fire and emergency evacuation drills included all required information. Evidence: 1. On 12-17-21, the facility?s fire drill record for 10-25-21 at 2:00 p.m. did not include the number of residents, special conditions simulated and any problems encountered. 2. The fire drill records for 11-22-21 at 650; 11-22-21 at 4:40 p.m.; 10-26-21 at 7 a.m.; 9-8-21 at 2-330 a.m. and 7-8-21 at 2-330 did not include documentation of the number of residents, the method used for notification of the drill, any special conditions simulated, weather conditions and problems encountered, if any. 3. Staff #1 and #2 acknowledged the facility fire drills provided for review did not include all of the required information.
Plan of Correction:	What Has Been Done to Correct? The Maintenance Director/Designee will conduct the required fire and emergency evacuation drills to include required documented information. How Will Recurrence Be Prevented? An alert file will be maintained to ensure required fire and emergency evacuation drills are completed and include required documented information. Person Responsible: Maintenance Director/ Designee and Administrator/Designee Due Date: 01/12/22