VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harbor at Renaissance
422 William Mills Drive
Stanardsville, VA 22973
(434) 985-4481

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Feb. 9, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

1.It would be helpful if all staff files were set up the same to make it easier to ensure all info in file is current. 2. Discuss with pharmacy printing what to do if symptoms persist consistently on the MAR and additional parameters as related to the use of insulin. These were on the physician order sheets but not consistently transcribed to MAR.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/09/2023 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Outside inspections current. Emergency and related drills complete. Maintenance continues to monitor water temps due to previous issues. All staff trained on emergency generator. Postings as required. Additional Comments/Discussion: Facility was clean and odor free. Increased staff training is now taking place. Specific staff will be participating in upcoming provider training. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with two applicable standards or law, and violations were documented on the violation notice issued to the facility. The licensee had the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on a review of service plans found in resident records, the following plans did not contain information reflecting assessed needs of the resident: Resident B ? Assessed behaviors and interventions are not addressed nor are visitation restrictions. Resident C ? Assessed behaviors and interventions are not addressed. Resident E ? Hospice services need to be added to the plan. Resident F ? Entire plan needs review and update to include change in Parkinson?s and fall risk, diet, snacks for weight gain, monitoring blood glucose by observation for apparent highs or lows.
Plan of Correction:	The needed corrections were recorded at the time of the inspection and are being addressed along with review of all ISPs by nursing staff. Corrections and future compliance are the responsibility of the nursing staff along with monitoring by the administrator.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of the January 2023 medication administration record (MAR) for resident F, insulin was not administered as per the physician?s order via sliding scale on three different days: Noon 1/4 BG 399 4 units given should have been 5 units. Noon 1/18 BG 293 5 units given should have been 3 units. 5pm 1/29 BG 202 1 unit given and should have been 2 units. There was no indication of harm on these occasions as per daily notes.
Plan of Correction:	All medication aides will receive additional training regarding sliding scale insulin dosing and documentation. This will be conducted and documented by nursing staff and administrator. Nursing staff will continue to monitor sliding scale MAR to ensure correction and ongoing compliance.