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: Aug. 17, 2023

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 08/17/23 from 8:16am to 4:55pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (self-reported incident) was received by VDSS Division of Licensing on 08/04/2023 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents in the safe, secure unit was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-110-1
Description:	Based on the record review and staff interview the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, inform, or disabled. Evidence: 1. The record for resident #1 contains a self-report completed by the facility for an incident on 07/30/23 documenting the following: staff #4 ?heard resident #1 calling for help while in the living room with staff #3, after approximately 5 minutes of hearing the resident call for help, staff #4 checked on resident #1 and saw resident #1 holding on to the seat of the recliner so the resident would not fall down. Staff #4 reported staff #3 was sitting in the chair across from resident #1 watching the resident.? Staff #3 was terminated at the conclusion of the facility?s investigation ?it was determined the investigation was founded and resulted in neglect of the resident. 2. During an interview on 08/17/23 with staff #4, staff #4 confirmed to have observed staff # 3 on 07/30/23 fail to offer assistance to resident #1 during the time the resident was calling for help (approximately 5 minutes) and when the resident was face down on his belly on the recliner with his legs on the floor holding on to the recliner so he would not fall down.
Plan of Correction:	Step 1: The facility maintains a zero-tolerance policy for resident abuse or neglect. The facility staff immediately reported the incident, and an investigation was initiated. The staff member was immediately removed from the schedule during the investigation. The allegations were determined to be founded and the staff member is no longer employed by the facility. The facility filed a self-report to the state of Virginia Step 2: This alleged deficient practice has the potential to impact all residents. We will conduct an audit of incident reports and complaints from the past six months to identify any other instances where staff members may not have demonstrated considerate and respectful behavior towards residents. Any identified cases will be thoroughly addressed and necessary corrective actions taken. Step 3: To prevent the recurrence of this deficiency, we will focus on reinforcing the importance of resident rights, dignity, and sensitivities through targeted education for all staff members, especially those responsible for direct care. The nurse educator will incorporate scenario-based training into our ongoing staff development program, emphasizing respectful communication, timely response to resident needs, and the importance of reporting any concerns. Step 5: The corrective actions will be completed by September 30, 2023. This timeframe allows for the swift implementation of resident care plan revisions and comprehensive staff education.