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: Nov. 9, 2022 and Nov. 10, 2022

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Mixed Population Safe, Secure Environment

Comments:

Date of Inspection: November 9 and 10, 2022 Type of Inspection: Renewal 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 72 Number of records reviewed and interviews conducted- 13 records (staff and resident), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meal times and during activities. The Licensing Inspector reviewed the following at the time of inspection: fire drills, pharmacy review, dietician report, healthcare oversight and menus. 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).

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on staff review, it was determined that the facility failed to report incidents to the division of licensing as required. Evidence: At the time of inspection, staff stated that the required incident reports had no been sent to the licensing inspector as required.
Plan of Correction:	Facility will ensure reporting incidents as required. In-service provided to the healthcare director. Executive Director/designee will monitor facility's reportable incidents monthly. All findings will reviewed at the QA meeting for continued improvement and analysis.
Standard #:	22VAC40-73-260-C
Description:	Based on direct observation and staff interview, it was determined that the facility failed to post the listing of all staff who have current certification in first aid and CPR. Evidence: At the time of inspection, direct care staff stated that there was no current first aid and CPR listing posted to inform staff as required.
Plan of Correction:	Corrections mad immediately on the day of the inspection. Previously scheduled CPR/first aid training completed on 11/15/2022. Business Office Manager (BOM) and health care director (HCD) will monitor CPR certifications, update the CPR list monthly, and posted on each required area. BOM/HCD educated on the requirements. Process will be monitored by the Executive Director/designee every 3 months. All findings will be reviewed at the QA meeting for continued improvement and analysis.
Standard #:	22VAC40-73-610-B
Description:	Based on direct observation by the Licensing Inspector, it was determined that the current menu was not posted in the special care unit. Evidence: November 9 and 10, 2022, there was no current menu posted in the special care unit as required.
Plan of Correction:	Weekly menus posted on the special care unit menu board. Dining services will ensure menus are available and posted on all required areas. Process will be monitored by the Dining service director/Executive Director/designee weekly. All findings will be reviewed at the QA meeting for continued improvement and analysis.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, it was determined that the staff failed to administer medication in accordance with physician's orders. Evidence: Resident E had a physician order for Tramadol HCL 50mg. There was no documentation of this order on the MAR. Staff did not know to administer this to the resident as ordered. Resident G had a physician order for Colchicine 0.6mg. There was no documentation of this order on the MAR. Saff did not know to administer this to the resident as ordered.
Plan of Correction:	Physician orders and MARs reviewed. Updates were made. Healthcare Director, nurses and medication aids re-educated on the medication administration requirements. Monthly audits will be conducted by the healthcare director/executive director/designee. All findings will be reviewed at the QA meeting for continued improvement and analysis.
Standard #:	22VAC40-73-870-E
Description:	Based on staff interview and direct observation, it was determined that the facility failed to keep equipment in good repair as required. Evidence: The signaling call bell devices for all residents are not in good repair. The facility has not replaced faulty signal bells as required.
Plan of Correction:	The call bell system and the devices checked and findings are reviewed with service contractor. Report system updated. Low battery reports reviewed and batteries replaced. Maintenance director/designee will monitor system reports daily. Monthly audits will be conducted by the Executive director/designee. All findings will be reviewed at the QA meeting for continued improvement and analysis.
Standard #:	22VAC40-73-970-A
Description:	Based on review of documentation requested and provided, the facility failed to ensure that fire drills were conducted on each shift in a quarter and no conducted in the same month. Evidence: At the time of inspection, the facility did not produce the current documentation of the fire drillsas required. The fire drills provided were dated:3/30/22 (11:15pm), 4/14/22 (10:50am). There were no fire drills provided for 5/22.
Plan of Correction:	Records reviewed for missing reports. Fire drills scheduled per the regulations. Maintenance Director educated on the fire drill requirements and record keeping. Process will be monitored by the Executive director/designee with monthly audits. All findings will be reviewed at the QA meeting for continued improvement and analysis.