VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbor's Edge
One Colley Avenue
Norfolk, VA 23510
(757) 233-0475

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Sept. 12, 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

Technical Assistance:

22VAC40-73-450 22VAC40-73-1140

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: 09/12/2023. 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: 46 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: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 2 residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, and the staff schedule. Water temperature was measured, and the call bell system was monitored. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

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: 1. The serious cognitive assessments for Resident #3 (dated 09/01/22) and Resident #4 (dated 06/28/21) indicate the resident is able to recognize danger or protect their own safety and welfare and the residents reside in a safe, secure environment.
Plan of Correction:	Corrected immediately and placed in the charts.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #3 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of Correction:	Documentation for Resident #3 completed and placed in chart.
Standard #:	22VAC40-73-40-B-8
Description:	Based on observation, the facility failed to ensure that the current license is posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. During a tour of the facility, the current license was not posted in the facility in a place conspicuous to the residents and the public.
Plan of Correction:	Current licensure is now hanging up in a common area visible to the residents and the public.
Standard #:	22VAC40-73-50-B
Description:	Based on record review, the facility failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative. Evidence: 1. Resident #3 (admitted 09/29/2022) did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their resident record.
Plan of Correction:	Awaiting family response to have documents signed. Goal completion date to have documents signed and in the medical record is 10/6/2023.
Standard #:	22VAC40-73-310-D
Description:	Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission. Evidence: 1. There was no evidence of written assurance to Resident #3 or their legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission.
Plan of Correction:	Corrected immediately ? All written assurances in place for the special care unit.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument is completed as required by 22VAC30-110 for private pay individuals. Evidence: 1. The UAIs for Resident #3 (dated 09/01/2022) and Resident #4 (dated 12/16/2022) were not signed for approval by the administrator or designee.
Plan of Correction:	Corrected 9/29/2023 ? Administrator?s approval signature obtained on the UAIs for Resident?s 3 and 4. 100% review to be completed on all updated UAIs for Administrator?s signature by 10/6/2023.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #3 admitted to hospice on 11/28/2022; however, Resident #3?s ISP (dated 09/01/2022) did not indicate the resident began hospice services or reflect this significant change.
Plan of Correction:	100% audit completed on ISPs to reflect any significant changes to resident?s care including, but not limited to hospice care.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. During a tour of the facility, the menu for the meals for the current week were not posted in an area conspicuous to residents.
Plan of Correction:	Corrected immediately ? All dining menus are hanging in a conspicuous area in the dining room. We will be going towards the digital signage in the next few months.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: an unlabeled bottle of Aspirin 81 mg tablets expired 02/2023, Midodrine HCI 10 mg tablets expired 07/31/2023 for Resident #6, and Omeprazole DR 20 mg capsules expired 07/31/2023 for Resident #7.
Plan of Correction:	All expired medications removed immediately. Staff/supervisor education with implementation of ensuring medication cart checks are being completed timely, to include the assurance of expired medications being discarded ? Will be completed by 10/6/2023.
Standard #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure a medicine cabinet, container, or compartment be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice. Evidence: 1. During a medication observation with Staff #1 in the safe, secure environment, a cup with medications (3 tablets and 1 capsule) were noted on top of the medication cart. Staff #1 left the medications on top of the medication cart in the dining area unattended to administer medications to Resident #5 in their apartment.
Plan of Correction:	Corrected immediately ? Staff involved were immediately educated on correct procedures. All staff will be educated on correct procedures when walking away from the medication cart during med pass by 10/6/2023.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee. Evidence: 1. The criminal history record report for Staff #2 (hired 01/03/2023) was obtained on 03/22/2023.
Plan of Correction:	A 100% audit has been conducted by Human Resources on all criminal history reports after the assisted living mock survey. Although this employee was identified at that time, the violation still exists due to the date obtained.