VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Oakbrooke
301 Clearfield Avenue
Chesapeake, VA 23320
(757) 315-6900

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

Inspection Date: April 27, 2023 and May 5, 2023

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 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: 4/27/2023 and 5/5/2023 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed:6 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 6 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 Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1070-A
Description:	Based on observation, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be in accessible to the resident except under staff supervision. Evidence: 1. During the on-site inspection of the safe, secure unit, the kitchen door was propped open and there was liquid lavender pot and pan detergent in resident reach. 2. Staff #1 acknowledged the door was open and the detergent was within resident reach.
Plan of Correction:	All directors and staff will ensure this door is shut and inaccessible.
Standard #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents are assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: Resident #3 was admitted to the facility on 3/14/23 and is in the safe, secure unit. The resident?s record did not contain an assessment by a clinical psychologist or independent physician which states the resident has a serious cognitive impairment due to dementia and has an inability to recognize danger or protect their safety and welfare.
Plan of Correction:	All SCU residents will have an assessment of serious cognitive impairment completed by their physician prior to admission into SCU.
Standard #:	22VAC40-73-250-C
Description:	Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description. Evidence: Staff #1?s file did not contain documentation of a signed job description. The signature line was blank.
Plan of Correction:	All staff will sign their job descriptions upon hire and will be maintained in their personnel file. BOM will ensure compliance with the standard.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: 1. Staff #5?s file did not contain documentation the staff member completed First Aid. 2. Staff #3?s file contained documentation the staff member?s First Aid expired on 9/1/2022.
Plan of Correction:	All direct care staff will have current CPR/First Aid. A tickler has been created to ensure compliance with the standard.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge. Evidence: During the on-site inspection on 4/27/2023 there was no posting of the current on-site person in charge.
Plan of Correction:	Manager on Duty posting is at the front desk and visible at all times. ED will ensure compliance with the standard.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions without required documentation. Evidence: Resident # 4 has physician?s orders for Ativan and Haloperidol and there were no psychotropic treatment plans in the resident record at the time of inspection.
Plan of Correction:	All psychotropic medications will have a treatment plan on record completed by the physician. HCD or MCD will ensure compliance with the standard.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician which includes the results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident # 3?s date of admission was 3/14/23. There was no initial physical or TB assessment in the resident file for licensing inspectors to review at the time of inspection.
Plan of Correction:	All residents will have a TB screening completed no more than 30 days prior to admission. HCD, MCD, or Marketing Director will ensure compliance with the standard.
Standard #:	22VAC40-73-320-B
Description:	Based on the review of facility records with the facility Administrator the facility failed to ensure that a risk assessment for tuberculosis was completed annually on each resident. Evidence: 1. Resident # 4?s date of admission was 3/6/2020. The last documented TB evaluation in the resident?s record was dated 3/1/2022. 2. Resident #7?s date of admission was 10/29/2021. The last documented TB assessment in the resident?s record at the time of the inspection was dated 10/22/2021.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on review of resident record, the facility failed to ensure that uniform assessment instruments (UAIs) are completed as annually and as required. Evidence: 1. Resident #4?s last documented UAI was dated 3/6/2021. 2. Resident #6?s last documented UAI was dated 9/6/2021. 3. Resident #5?s file did not contain a UAI for the inspector to review at the time of inspection.
Plan of Correction:	All resident UAIs and ISPs are current. A tickler is in place to ensure compliance. HCD or MCD will ensure UAIs and ISPs are updated at least annually or as needed.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) completed within 30 days after admission. Evidence: 1. Resident #3?s date of admission was 3/14/2023 and Resident # 5?s date of admission was 12/12/2022. There were no comprehensive ISPs in the residents? records for the licensing inspectors to review at the time of inspection. 2. Staff #2 acknowledged there was no comprehensive ISPs for inspectors to review at the time of the inspection.
Plan of Correction:	All residents will have a comprehensive ISP in place no more than 30 days after admission. HCD and MCD will ensure compliance with the standard.
Standard #:	22VAC40-73-450-E
Description:	Based on resident records review and staff interview, the facility failed to ensure the individualized service plans (ISP) were updated annually or as needed for a significant change of a resident?s condition. Evidence: 1. Resident #4`s ISP was last reviewed on 3/6/2021.
Plan of Correction:	UAIs and ISPs will be updated upon significant change in resident needs. HCD or MCD will ensure compliance with the standard.
Standard #:	22VAC40-73-460-H
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing - at least twice a week, but more often if needed or desired. Evidence: 1. There were no documented showers in the facility?s shower logs for residents in the safe, secure, unit for the month of April 2023. 2. Staff #1 acknowledged the shower logs were not completed per the facility?s standards.
Plan of Correction:	Shower logs are in place and care staff are aware of their duty to document. HCD and MCD will ensure compliance of the standard.
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the facility on 4/27/2023, the facility failed to have the menu for the current week posted. Evidence: During the on-site inspection on 4/27/23, the daily posted menus for breakfast and lunch were dated for 4/26/23. There was no weekly menu posted.
Plan of Correction:	Weekly and daily menus are posted in conspicuous and visible locations. Dining Services Director or designee will ensure menus are posted per the standard.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: 1. The facility Medication Management Plan states, ?Narcotics and other controlled substances will be counted shift to shift between the on-coming and off-going medication staff. Direct staff to staff hand off of the keys to the medication carts will take place after a correct inventory has been documented. 2. A review of the Controlled Medication Count Record for the medication cart in the safe, secure unit for the month of April 2023, showed staff failed to ensure counts of all control medications were documented on 22 out of 27 days reviewed.
Plan of Correction:	All staff that are responsible for administering medications have been trained on the narcotic count procedures. HCD and MCD will ensure compliance with the standard.
Standard #:	22VAC40-73-650-A
Description:	Based on a review of resident records the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. The May 2023 Medication Administration Record (MAR) for Resident #6 shows the resident is currently receiving Aspirin 81 mg, Atorvastatin 10 mg, Calcium 600+, Clonidine HCL 0.1mg, Donepezil HCL 5mg, multivitamin tablet, and Sertraline HCL 25 mg tablet. There were no signed physician?s orders available for the inspector to review at the time of inspection. 2. Staff #2 acknowledged there was no signed physician?s order in the resident file for the licensing inspector to review at the time of inspection.
Plan of Correction:	All medications, diet changes, or other orders will have a signed physician order on file. HCD or MCD will ensure any changes to medications, diets, etc. will have a signed physician order on file before a change is made.