VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Falls Run
60 Brimley Drive
Fredericksburg, VA 22406
(540) 479-3788

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Feb. 9, 2022 and Feb. 11, 2022

Complaint Related: Yes

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 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:

Date of Inspection: February 9 and 11, 2022 Type of Inspection: Complaint Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 73 Number of records reviewed and interviews conducted- 6 resident records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). The residents were observed during activities and lunch time. The Licensing Inspector reviewed Medication Administration Records, facility policies, menus and activity schedules.

Violations:

Standard #:	22VAC40-73-1020-A
Complaint related:	No
Description:	Based on direct observation by the Licensing Inspector, it was determined that there were not two staff on the secured needs unit for the care and supervision of the residents. Evidence: On February 11, 2022, the Licensing Inspector observed only one staff member on the secured needs unit at 8:50am.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on resident record reviews and staff interviews, it was determined that the facility staff failed to follow corporate policies during a physical plant emergency. Evidence: Staff failed to document the administration of medications for residents in care on hard copy paperwork during an ice storm while there was no power to various levels within the building. The Director of Nursing stated that staff did administer the medications as ordered but there was no indication of this on the documentation.
Plan of Correction:	Not available online. Contact Inspector for more information.