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: May 30, 2024

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 22VAC40-80 THE LICENSE

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: 5/30/2024 8:10 am- 2:30 pm 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: 60 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector observed activities being conducted, a meal, and medication passes. 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 #:	22VAC40-73-40-B
Description:	Based on staff record review, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for an employee. Evidence: 1. During the inspection conducted on 5/30/224, a record review indicated the date of hire for Staff #4 was 12/19/2023. The staff?s record did not contain a completed criminal history record report. 2. Staff #1 acknowledged the record did not contain a criminal history record report.
Plan of Correction:	ED and BOM will utilize the new hire checklist to ensure all new hires have a submitted criminal background request prior to the employee starting. The staff member who did not have a criminal background check on file has one on file now and remains employed at the community.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member who did not have current certification in first aid shall receive certification in first aid within 60 days of employment. Evidence: The employee file for Staff #4 (D.O.H) 12/19/2023 did not contain evidence of the staff member having First Aid certification.
Plan of Correction:	ED and BOM will ensure all direct care staff obtain their First Aide and CPR within 60 days of their start date. ED and BOM will utilize the new hire checklist. Current staff who do not have their FA/CPR will attend a class within the next 2 months.
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: On the date of the inspection 5/30/2024, the posting of the on-site person in charge was not accurately updated to reflect the person who was in charge of the building at the time the inspector entered the building.
Plan of Correction:	ED updated the posting for the on-site person in charge. ED will ensure the posting remains accurate and is visible at the front desk.
Standard #:	22VAC40-73-430-H-1
Description:	Based on review of resident record, the facility failed to ensure that a discharge statement included all the required information listed in the standards to be provided to the resident and as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: 1. The file for Resident #1 did not contain a discharge statement. 2. Staff #1 acknowledged the file did not contain a discharge statement.
Plan of Correction:	ED and BOM will ensure each resident has a discharge statement completed upon move out.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified. Evidence: 1. Resident #3?s UAI dated 5/3/2024 stated the resident needed mechanical and supervision assistance in bathing. The resident?s ISP dated 5/3/2024 stated the resident only required mechanical assistance to complete bathing. 2. Resident #3?s UAI dated 5/3/2024 stated the resident was disoriented some spheres, some of the time. The resident?s ISP dated 5/3/2024 stated the resident was oriented to all spheres. 3. Resident #6?s UAI dated 5/1/2024 stated the resident did not need assistance in eating. The resident?s ISP dated 5/1/2024 stated the resident needed supervision in eating. The resident?s UAI stated the resident did not perform stairclimbing. The resident?s ISP stated the resident required mechanical and physical assistance in the area of stairclimbing. 4. Resident #5?s UAI dated 3/22/2024 stated the resident only required mechanical assistance in walking. The ISP dated 3/22/2024 stated the resident required mechanical and supervision assistance in walking.
Plan of Correction:	HCD and HSD will ensure assessed needs on the UAI are accurately reflected on the ISP. ED will audit each UAI and ISP to ensure assessed needs are accurately reflected as well.
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. A review of the Controlled Medication Count Record for the medication carts on the 2nd and 3rd floors for the month of May 2024 documented staff failed to ensure counts of all controlled substances were documented on 31 out of 31 days reviewed. 2. Staff members 2,3, and 5 all acknowledged the Controlled Medication Count Records were incomplete.
Plan of Correction:	ED, HCD, and HSD will audit narcotic inventory count sheets on a daily basis. RMAs will be retrained on their responsibility to accurately count and sign off on narcotic inventory sheets.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding methods to ensure that each resident?s prescription medications and over-the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. The facility?s Medication Management Plan states that, ?Nurses and RMA?s shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered.? The policy further states, ?If a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician?s instructions will be documented on the (E) MAR.? 2. A review of the May 2024 MAR for Resident #3 documented the resident?s Symbicort Inhaler was not available to be administered on 5/3/2024, 5/6/2024, 5/8/2024, 5/10/2024, 5/12/2024. The resident?s Lidocaine 4% pain patch was not available to be administered on 5/14/2024. The resident?s Furosemide 20 mg was not available to be administered on 5/29/2024. The Metoprolol tartrate 25 was not available to be administered on 5/29/2024 and the Venlafaxine HCL 75mg was not available to be administered on 5/29/2024. 3. A review of the May 2024 MAR for Resident #10 documented the resident?s Alprazolam 0.25 mg table was not available to be administered on 5/3/2024, 5/4/2024, 5/5/2024, 5/6/2024, 5/7/2024, 5/8/2024,5/9/2024, 5/24/2024, 5/25/2024, 5/26/2024, and 5/27/2024. The resident?s tramadol 50 mg was not available to be administered on 5/8/2024, 5/8/2024 and 5/9/2024.
Plan of Correction:	4 HCD and HSD or designee will audit medication availability twice per week. RMAs will be retrained on their responsibilities regarding ordering of medication in a timely manner, notifying a supervisor if there is an issue with obtaining a medication, and notifying the physician if a medication becomes unavailable.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the center failed to post the findings of the most recent inspection of the facility. Evidence: During an inspection of the center on 5/30/2024, the findings of the most recent inspection of the center were not observed to be posted.
Plan of Correction:	ED will ensure that the DSS Inspection binder is readily available and within sight for anyone who wants to review them. The binder is kept on the counter at the front desk.