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: July 21, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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: 7/21/2023 8:30 am- 2:00 pm 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 7/20/2023 regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: 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: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector observed a meal and an activity in the safe secure unit. Additional Comments/Discussion: 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 #:	22VAC40-73-1110-A
Complaint related:	No
Description:	Based on record review the facility failed to ensure the administrator?s justification for the resident placement in the safe, secure environment was documented and retrained in the resident?s file. Evidence: The Approval for Placement in Special Care Unit form for resident #2 was missing the administrator?s justification for the resident?s placement in the safe, secure environment.
Plan of Correction:	1. An Approval for Placement in Special Care Unit form will be obtained for Resident #2. 2. A 100% audit on current Memory Care residents will be completed to ensure Approval for Placement in Special Care Unit forms are completed and compliant. 3. An in-service will be held with staff on the Approval for Placement in Special Care Unit Form and 22VAC40-70-1110-A. 4. The Memory Care Coordinator will monitor for compliance.
Standard #:	22VAC40-73-1180-A
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. During an inspection of the safe, secure unit the laundry room door was open and Xtra laundry detergent was observed within resident reach. 2. During an inspection of resident # 4?s room, the following items were observed unlocked: deodorizer, Lysol spray, and deodorant. 3. Staff # 1 acknowledged the items were observed in resident?s # 4?sroom were unlocked and within the resident?s reach.
Plan of Correction:	1. The laundry room door was closed immediately. 2. Resident #4?s personal items were immediately secured and locked. 3. Multiple daily rounds and room sweeps are made to ensure personal items are secure and locked. Rounds are made to ensure that the laundry room is locked. 4. The Memory Care Coordinator will monitor the laundry room door and residents? personal items for compliance.
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on resident records review and interviews with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of a resident. Evidence: 1. Resident #1 had a documented fall on 4/16/2023. This fall was not reported to the regional licensing office. Resident #1 had another fall on 6/17/2023, this fall resulted in the resident going to the emergency room. This incident was not report within 24 hours. The incident was reported on 6/20/2023. 2. Resident #2 had a documented fall on 7/14/23 in which she was found crawling on the floor and complained of right leg pain. She was later seen by the hospice nurse and an x-ray was ordered. This incident was not reported to the regional licensing office.
Plan of Correction:	1. The Executive Director will review all incidents daily to ensure that any reportable incidents are reported and within 24 hours. 2. Staff will be educated on reportable incidents and compliance with 22VAC40-7370-A. 3. All incidents will be reviewed in the daily stand up meeting. 4. Executive Director will monitor all incidents for compliance.
Standard #:	22VAC40-73-310-D
Complaint related:	No
Description:	Based on record review and staff interviewed, the facility failed to ensure prior to admission of a resident, the facility administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. Acknowledgement of this document should be signed by the resident or a legal representative and kept in the resident?s record. Evidence: 1. The record for resident # 2 did not contain a signed written assurance by the resident or the resident?s representative. 2. Staff members #1 and #2 acknowledged the document was not signed.
Plan of Correction:	1. Resident #2 record will be updated with a signed written assurance. 2. All current memory care residents? records will be reviewed to ensure written assurances are signed. 3. An in-service will be held to review compliance with 22VAC40-73-310-D. 4. The Memory Care Coordinator will monitor for compliance.
Standard #:	22VAC40-73-310-H
Complaint related:	No
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: A review of resident # 3?s record documented the resident had a physician?s order for Aricept. The resident?s record did not contain a signed psychotropic treatment plan for the medication.
Plan of Correction:	1. Resident #3?s psychotropic treatment plan will be signed. 2. The psychotropic treatment plans for current memory care residents will be reviewed to ensure signatures and compliance. 3. An in-service will be held with RMAs/LPNs to review psychotropic treatment plans and compliance with 22VAC40-73-310-H. 4. The Memory Care Coordinator will monitor for compliance.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. Evidence: Resident #2 had a documented fall on 7/14/23 however the most recent fall risk assessment provided at the time of inspection was dated 4/6/23.
Plan of Correction:	1. Resident?s #2?s fall risk assessment was updated to reflect the most updated fall. 2. RMA?s/LPN will be educated on the fall risk assessment policy. 3. A 100% of all current resident?s in memory care will be audited to ensure updated fall risk assessments. 4. The Memory Care Coordinator will monitor fall risk reports to ensure compliance.
Standard #:	22VAC40-73-380-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information document was kept current. Evidence: The personal/social data sheet for resident # 3 did not list all the resident?s allergies. The resident?s allergies to Quinapril and pollen were not listed.
Plan of Correction:	1. Resident #3?s personal/social data sheet was updated to reflect an allergy to Quinapril. 2. An in-service will be held with staff to discuss compliance with 22VAC40-73-380-B. 3. A 100% audit will be completed on all memory care resident?s personal/social data to ensure all allergies are documented. 4 . The Memory Care Coordinator will monitor personal/social data for compliance.
Standard #:	22VAC40-73-410-A
Complaint related:	No
Description:	Based on record review and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for a new resident and their legal representative. Evidence: 1. Resident #2 was admitted on 3/21/23 and the resident?s record did not contain verification the resident or the resident?s representative received an orientation. 2. Staff members #1 and #2 acknowledged the resident file reviewed at the time of inspection did not contain documentation the resident received an orientation.
Plan of Correction:	1. Resident #2?s R.P. will receive orientation. 2. All current memory care resident?s records will be reviewed to ensure all residents/R.P. s received orientation. 3. An in-service will be held to review orientation and compliance with 22VAC40-73-410-A. 4. The Memory Care Coordinator will monitor for compliance.