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: Sept. 8, 2022 and Sept. 9, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 22VAC40-80 THE LICENSE

Technical Assistance:

Breakfast Menu Updating Discharge Summary and Approval for Specialized Care Unit form to include statement with current standard.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection was initiated on 09/08/22 from 8:51am to 4:25pm and on 09/09/22 from 8:39am to 4:03pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and two activities for Assisted Living and one activity for the Special Care Unit were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts for assisted living and the special care unit, emergency preparedness plan, fire inspection report, health inspection report, staffing schedule, first aid kits, and resident council meeting minutes. Water temperature was checked in one resident room. Call Bells for two residents were checked and staff responses were observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the posted listing of staff certifications in first aid or cardiopulmonary resuscitation (CPR) or both was kept up to date. Evidence: 1. The First Aid and CPR list posted in the facility included staff who are no longer employed with the facility. 2. The First Aid and CPR posting included an expiration date of 9/01/22 for Staff #2 First Aid and CPR certification. This is inconsistent with Staff #2 record which documents an expiration date of 10/01/23 for First Aid and CPR certification. 3. Staff #6 and Staff #7 acknowledged the First Aid and CPR posting was not kept up to date.
Plan of Correction:	Human Resources staff shall ensure the CPR/First Aid list is updated routinely. They shall ensure all employees that are no longer with the company are removed from the list. The listing will be sent at least monthly and after every change/update. The Unit Manager and/or designee shall ensure that a monthly list is received and review it for accuracy prior to posting for staff to have readily accessible.
Standard #:	22VAC40-73-450-C
Description:	Based on record review the facility failed to ensure the ISP included a description of identified needs based upon the UAI. Evidence: 1. The Uniformed Assessment Instrument (UAI) for Resident #7 dated 7/05/22 documented a need for human help supervision for toileting. The ISP did not address the identified need, nor the service to be provided by the facility for resident #7. 2. The UAI for Resident #7 dated 7/05/22 documented a need for mechanical help for transferring. The ISP did not address the identified need, nor the service to be provided by the facility for resident #7. 3. The UAI for Resident #7, dated 7/05/22 documented resident bladder is incontinent and needs help. The ISP did not address the identified need, nor the service to be provided by the facility to resident #7.
Plan of Correction:	The resident?s UAI and ISP has been updated, to ensure they reflect each other To ensure the UAI and ISPs remain current and include all updates, the physician?s orders and ADL tasks will be reviewed at the weekly risk meetings by the Assistant Administrator and/or designee. The resident?s ISP and/or UAI will be reviewed to ensure the changes are made in them and both reflect the same information.
Standard #:	22VAC40-73-450-E
Description:	Based on the onsite record review, the facility failed to ensure the ISP (Individualized Service Plan) shall be signed and dated by the resident or the legal guardian. Evidence: 1. The ISP for Resident #1 dated 9/08/22 did not include a signature of the resident or the legal guardian. 2. The ISP for Resident #2 dated 9/08/22 did not include a signature of the resident or the legal guardian. 3. The ISP for Resident #3 dated 8/24/22 did not include a signature of the resident or the legal guardian. 4. The ISP for Resident #4 dated 8/10/22 did not include a signature of the resident or the legal guardian. 5. The ISP for Resident #6 dated 8/18/22 did not include a signature of the resident or the legal guardian. 6. The ISP for Resident #7 dated 8/10/22 did not include a signature of the resident or the legal guardian.
Plan of Correction:	All ISP (Individualized Service Plans) will be signed and dated by both the resident and the legal guardian at the time of the change. If a representative chooses to conduct the meeting via phone or web-based meeting, Assistant Administrator or designee shall send the form to the person for signature.
Standard #:	22VAC40-73-680-D
Description:	Based on review of resident Medication Administration Records (MAR) the facility failed to ensure medication shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standard of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. The MAR for Resident #1 dated 8/01/22-8/31/22 did not include documentation for the date of 8/18/22 and 8/21/22 for medication administration or omission for resident #1 prescribed medication of Levo-T Tablet. Per the physician?s order resident #1 is prescribed Levo-T Tablet 75mcg to be given by mouth one time a day. 2. The MAR for Resident #1 dated 8/01/22-8/31/22 did not include documentation for 8/06/22 to include the evening and night shift for medication administration or omission for resident #1 prescribed medication of Calmoseptine Ointment. Per the physician?s order, resident #1 is prescribed Calmoseptine Ointment to be applied topically every shift. 3. Resident #2, MAR dated 8/01/22-8/31/22 did not include documentation for the date of 8/18/22 and 8/21/22 for medication administration or omission for resident #2 prescribed medication of levothyroxine sodium tablet mcg. Per the physician?s order resident #2 is prescribed levothyroxine sodium tablet to be given by mouth one time a day.
Plan of Correction:	Unit Manager and/or Clinical Educator shall conduct medication trainings to all licensed nursing staff /Medication Aides to ensure an understanding of the process of the medication pass. Unit Manager and/or designee shall conduct weekly medication observations to ensure staff competency.