VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Harbour View
5871 Harbour View Boulevard
Suffolk, VA 23435
(757) 214-6279

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Jan. 10, 2023 and Jan. 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 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

Ensure the availability of the emergency food supply does not include expired items.

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: An unannounced renewal inspection took place on 01/10/23 at 8:35 am to 4:45 pm and 01/12/23 at 8:25 am to 3:40 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: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and an activity were observed. A medication pass observation was completed for four residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, fire inspection report, and a health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-200-C
Description:	Based on record review the facility failed to ensure Staff #1 met at least one of the direct care staff requirements listed in 22VAC40-73-200-C. Evidence: 1. Staff #1, hired 08/17/15, certified nursing aide license (CNA) expired 02/18/22. 2. During the onsite inspection, Staff #1 was observed providing direct care physical assistance to resident # 6 to include assisting resident to get up from a chair and providing physical support while walking with the resident to the bathroom. 3. Staff # 3 acknowledged the facility identified staff #1 as direct care staff and was not aware the staff?s CNA license was expired.
Plan of Correction:	Business Office Manager, Healthcare Director will have tickler system in place to check License monthly to ensure licenses are current. We are checking month prior and reminding employees.
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident. Evidence: 1. The record for resident #6, includes a risk assessment for TB dated, 06/27/21 and 01/10/23. There is no evidence in the record of a risk assessment for TB being completed annually in the year of 2022.
Plan of Correction:	Healthcare Director will check TB screenings monthly to ensure they are up to date.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to complete the Uniform Assessment Instrument (UAI) whenever there is a significant change in the resident?s condition. Evidence: 1. The record for resident # 2 contains a hospice evaluation and treatment physician order dated 11/17/22. The last completed UAI in the record is dated 09/24/22. 2. The record for resident #2 contains an Individualized Service Plan (ISP) with an updated dated of 11/18/22 which documents supports needed for Hospice Care. 3. The record for resident # 1 contains an approval for the safe, secure unit dated 12/07/22. The resident moved from the assisted living unit to the safe, secure unit on 12/07/22. 4. The record for resident #1 includes an ISP updated 12/07/22 documenting the supports needed for the safe, secure unit. The last UAI in the record is dated 09/05/22.
Plan of Correction:	Healthcare Director, Executive Director will ensure ISP are updated when care changes or annually.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the ISP shall be signed and dated by the licensee, administrator, or his designee, and by the resident or legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. The record for resident # 2 contains an ISP updated 11/18/22. The ISP update did not include a signature and date by the licensee, administrator, or his designee, and of the resident or legal representative. 2. The record for resident # 1 contains an ISP updated 10/11/22, 11/18/22, 12/07/22, and 12/15/22. The ISP updates did not include a signature and date by the licensee, administrator, or his designee, and of the resident or legal representative.
Plan of Correction:	Healthcare Director, Executive Director will ensure staff and family sign ISP when changes are made to ISP.
Standard #:	22VAC40-73-620-A
Description:	Based on the onsite review the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. Evidence: 1. The dietitian oversight report, dated 06/27/22 documented ?currently there are no residents on special diets.? 2. Observation of a posting in the kitchen labeled ?Special Diets? documented a list of mechanical soft and pureed diets for a total of 9 residents. The posting was not dated.
Plan of Correction:	Executive Director, Dining Service Director will ensure dietary oversight report is done and is correct quarterly and ensure special diets are reviewed.
Standard #:	22VAC40-73-670-1
Description:	Based on the record review the facility failed to ensure each staff person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Evidence: 1. Staff #1, hired 08/17/15, registered medication aide license expired 08/31/21. 2. During the medication pass observation, Staff #1 was observed administering medications to resident?s # 4, #6, and #10. 3. The record for staff #1 does not contain evidence of the staff being licensed by the Commonwealth of Virginia to administer medications.
Plan of Correction:	Business Office Manager, Healthcare Director will ensure tickler system is in place to ensure license of staff working are current.
Standard #:	22VAC40-73-970-A
Description:	Based on the onsite review the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall be conducted in the same month. Evidence: 1. The facility provided evidence of fire and emergency evacuation drills dated 03/20/22 and 11/16/22. There was no evidence of the facility conducting fire and emergency evacuation drills on each shift at least quarterly. 2. Staff # 3 acknowledged the facility did not have documentation of fire and emergency evacuation drills being conducted on each shift at least quarterly.
Plan of Correction:	Executive Director, Maintenance Director will put into place a monthly training and quarterly training of fire drills, resident emergencies.
Standard #:	22VAC40-73-990-C
Description:	Based on the onsite review the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. The facility did not provide evidence of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months. 2. Staff #3 acknowledged there is no evidence of documentation within the last two years of the facility practicing procedures for resident emergencies every 6 months.
Plan of Correction:	Executive Director, Maintenance Director will put in place resident emergency trainings for all staff every 6 month.
Standard #:	22VAC40-90-40-C
Description:	Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes. Evidence: 1. Staff # 4, hired 11/18/22, criminal record report contains convictions for two barrier crimes (18.2-57.2).
Plan of Correction:	Business Office Manager, Executive Director will review all new hires for barrier crimes and screen all new hires. Employee has been terminated