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: March 1, 2023

Complaint Related: Yes

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 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 8:05am-12:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Several complaints # 568987 & 568900 were received by VDSS Division of Licensing on 1/5/2023, 1/23/2023, and 2/20/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 27 Memory Care 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: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: 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 S hould you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on documentation reviewed, the facility failed to ensure that during night hours, when 23 to 32 residents are present, at least three direct care staff members shall be awake and on duty at all times in each special care unit. Evidence: The staffing sheet provided to the Licensing Inspector for 2/27/23 showed three staff members scheduled to work the overnight shift. There were two call outs and there was one substitution. This resulted in the unit having two staff members during the shift for the safe secure unit with 24 residents present.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-B
Complaint related:	No
Description:	Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee. Evidence: The UAI dated 1/1/2023 for Resident #3 did not contain an assessor signature or signature of the administrator or administrator designee.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record reviewed, the facility failed to have the Individualized Service Plan (ISP) signed by the resident or his/her legal representative. Evidence: The ISP dated 1/1/2023 for Resident #3 did not contain a resident or legal representative signature.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-580-D
Complaint related:	No
Description:	Based on record reviewed the facility failed to ensure when a resident UAI has been assessed as dependent in eating/feeding, the individualized service plan (ISP) shall indicate an approximate amount of time needed for meals to ensure needs are met. Evidence: Resident # 3 has a UAI (dated 1/1/23) which assessed the resident as being spoon fed by others. The ISP (dated 1/1/23) for Resident #3 does not indicate the approximate amount of time needed for meals.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on records reviewed, the facility failed to ensure medication be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. A review of the December 2022 Medication Administration Record (MAR) for Resident #4 documented the resident received medications late 26 out of 31 days. A review of the January 2023 MAR documented the resident received medications late 11 out of 12 days reviewed. 2. A review of the December 2022 MAR for Resident #5 documented the resident received medications late 16 out of 31 days. A review of the January 2023 MAR documented the resident received medications late 6 out of 6 days reviewed. 3. A review of the December 2022 MAR for Resident #6 documented the resident received medications late 27 out of 31 days. A review of the January 2023 MAR documented the resident received medications late 12 out of 12 days reviewed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on family interviews and documentation reviewed, the facility failed to ensure the two hour documented rounds in memory care were being conducted and included the time of the rounds. Evidence: Documentation provided by the facility indicated rounds were conducted for each resident in the memory care unit at the exact same time.
Plan of Correction:	Not available online. Contact Inspector for more information.