VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony on the Peninsula
3540 Victory Boulevard
Yorktown, VA 23693
(757) 447-3544

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Feb. 13, 2023

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/13/23 12:55pm- 4:50pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/7/2022 and 11/15/2022 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector toured the facility, observed a meal, and spoke with residents. Additional Comments/Discussion: Licensing Inspector shared tools the staff members could use to assist with auditing charts. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-B
Complaint related:	No
Description:	Based on review of resident record, the facility failed to ensure that each record contain a written acknowledgement of the receipt of the disclosure statement by the resident or his legal representative. Evidence: Written acknowledgement of receipt of disclosure of information regarding the facility was not present in the file of Resident #3
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-110-1
Complaint related:	Yes
Description:	Based on records reviewed and documentation submitted by the facility, the facility failed to ensure staff was considerate and respectful of the rights, dignity, and sensitives of person who are aged, infirmed, or disabled. Evidence: 1. The facility reported a physical incident occurred between a staff member and a resident on 10/26/2022. 2. The facility performed an internal investigation and found cause to terminate the staff member for facility violations which also violate Standard 110- 1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Complaint related:	No
Description:	Based on staff records reviewed, the facility failed to ensure each staff person member?s tuberculosis (TB) risk assessment be completed annually. Evidence: The TB risk assessment forms for Staff members #4 (dated 2/3/2021, 4/14/2022) and #3 (dated 12/03/2020, 1/24/2023) appeared to be presigned by the physician, photocopied, and the staff members checked their assessment risk.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-B
Complaint related:	No
Description:	Based on records reviewed the facility failed to document a required interview between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative occurred. Evidence: 1. The record for Resident #3 did not contain documentation of the required interview between the administrator or designee and resident or legal representative. 2. Staff #2 acknowledged the record provided to the licensing inspector at the time of the inspection did not contain the required documentation
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-D
Complaint related:	No
Description:	Based on resident record reviewed, the facility failed to provide written assurance to the resident or his legal representative ensuing that the facility has the appropriate license to meet the resident?s care needs at the time of admission. Evidence: The record of Resident #3 did not have a copy of the signed written assurance in the record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-410-A
Complaint related:	No
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives. Acknowledgement of having received the orientation shall be signed and dated by the resident and as, appropriate, his legal representative, and such documentation shall be kept in the resident?s record. Evidence: 1. Resident #3 was admitted to the facility on 5/2/2022 and there was no acknowledgement of orientation in the resident?s record. 2. Staff #3 acknowledged the record presented to the licensing inspector at the time of the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) was reviewed annually. Evidence: 1. The most recent UAI review date for Resident #2 was 5/11/2021. 2. Staff #1 acknowledged the most recent UAI was dated 5/11/2021.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that on or within seven days prior to the day of admission a preliminary plan of care is developed. Evidence: 1. Resident #4 was admitted to the facility on 11/28/2022. There was no initial or comprehensive service plan in the resident record. 2. Staff #1 acknowledged there was no preliminary or comprehensive service plan in the record provided to the licensing inspector at the time of the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure individualized service plan (ISP) shall be reviewed at least every 12 months and as needed as the condition of the resident changes. Evidence: 1. The last review date for the ISP of Resident #2 was 5/13/2021. 2. Staff #1 acknowledged the ISP dated 5/13/2021 was the most recent ISP for the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-720-A
Complaint related:	No
Description:	Based on review of resident records, the facility failed to ensure that a written DNR order was included in the individualized service plan (ISP). Evidence: Resident #2 has a DNR dated 1/22/2023 which was not included in the most current ISP dated 05/13/2021
Plan of Correction:	Not available online. Contact Inspector for more information.