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. 3, 2024 and Jan. 4, 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 63.2 GENERAL PROVISIONS 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:

Personal and Social Information

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 01/03/24 at 8:08 am to 5:08 pm and 01/04/24 at 8:50 am to 4:50 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: 6 Observations by licensing inspector: Breakfast was 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 #:	22VAC40-73-1090-A
Description:	Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been 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 record of Resident #7 contains an assessment of serious cognitive impairment dated 06/26/23 that includes the following documentation: a response of ?No? for the question ?does this individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia,? and a note that states ?patient does not have diagnosis of dementia but has increased confusion.? The resident?s record contains an approval and placement in the safe secure environment dated 06/26/23. 2. Resident?s #7 personal and social data includes a move in date to the facility as 07/25/23. Staff #7 confirmed resident?s #7 move in date to the facility?s safe secure environment as 07/25/23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-C
Description:	Based on the onsite record review and staff interview the facility failed to ensure training for the first year shall commence no later than 60 days after employment. Evidence: 1.The record for staff #1, hire date of 08/30/23, did not contain documentation of trainings completed by staff #1. 2.Staff #6 confirmed the record for staff #1 did not contain documentation of completed trainings.
Plan of Correction:	The administrator and Business office Manager will continue to audit employee training hours for next six weeks. ED will complete random audits to ensure ongoing compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1.The record for staff #2, hire date of 11/29/23, did not contain a risk assessment for TB. 2.Staff #6 confirmed the record for staff #2 did not contain a risk assessment for TB. 3.The record for staff #4, hire date of 05/30/23, contains a risk assessment for TB dated 09/15/23, which is after staff?s #4 hire date.
Plan of Correction:	Business Office Manager or designee will audit records for the next 6 weeks basis to make sure all required items are in the record and current for all employees. ED will complete random audits to ensure ongoing compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall include the following: results of a risk assessment documenting the absence of TB in a communicable form; the signature of the examining physician. Evidence: 1.Resident?s #1 physical examination dated 09/01/23 does not include the signature of the examining physician. 2.The record for resident #2, admission date 09/30/22, contains a physical examination dated 10/20/22, and a risk assessment for TB dated 10/28/22. The physical exam and risk assessment for TB is dated as completed after the resident?s admission date. Resident?s #2 personal data and the facility?s record documents the resident?s move in date to the facility as 09/30/22. 3. The record for resident #7, admission date 07/25/23, contains a risk assessment for TB dated 10/26/23, which is dated as completed after the resident?s admission date. Resident?s #7 personal data and the facility?s record documents the resident?s move in date to the facility as 07/25/23.
Plan of Correction:	ED or designee to audit charts for significant problems on History and Physicals, and ensure on new admissions, updates or change in status and ongoing.
Standard #:	22VAC40-73-350-B
Description:	Based on the record review the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertained and the date the information was ascertained. Evidence: 1.The record for resident # 1, admission date of 09/15/23, contains a sex offender screening dated 09/26/23. The sex offender screening for resident #1 is dated more than 3 days after the resident?s admission. Resident?s #1 progress notes document the resident?s move in date to the facility as 09/15/23. 2.The record for resident #2, admission date of 09/30/22, contains a sex offender screening dated 10/28/22. The sex offender screening for resident #2 is dated more than 3 days after the resident?s admission. Resident?s #2 personal data and facility?s record documents the resident?s move in date to the facility as 09/30/22. 3.The record for resident #3, admission date of 08/08/23, contain a sex offender screening dated 01/04/24. The sex offender screening for resident #3 is dated more than 3 days after the resident?s admission. Resident?s #3 personal data and facility?s record documents the resident?s move in date to the facility as 08/08/23. 4.The record for resident #7, admission date of 07/25/23, contain a sex offender screening dated 01/04/24. The sex offender screening for resident #3 is dated more than 3 days after the resident?s admission. Resident?s #7 personal data and facility?s record documents the resident?s move in date to the facility as 07/25/23.
Plan of Correction:	The assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if determined the potential resident will have a stay of three days or greater. The Administrator or designee will utilize the state approved sex offender registry database to ascertain this information. The community will create a move in check list that determines required move in documentation and Executive Director and/or designee will review all documentation prior to the resident moving into the community.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. Evidence: 1.The record for resident #1, admission date of 09/15/23, does not contain a UAI completed prior to admission. The UAI in the record is dated 10/17/23. 2.The record for resident #2, admission date of 09/30/22, does not contain a UAI completed prior to admission. The UAI in the record is dated as 10/31/22.
Plan of Correction:	The assessment process shall be completed prior to accepting residents to determine if they meet the criteria for assisting living at Harmony at Harbour View. Once residents move, assessment are reviewed within 30 days of move in, change of condition and annually. Assessments are completed by HCD or designee.
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1.The record for resident #1, admission date of 09/15/23 does not contain a preliminary plan of care completed on or within 7 days of admission. The ISP in the record for resident #1 is dated 10/17/23. 2.The record for resident #2, admission date 09/30/22, does not contain a preliminary plan of care completed on or within 7 days of admission. The ISPs in the record for resident #2 is dated 11/01/22 and 11/12/23.
Plan of Correction:	A preliminary plan of care must be developed on or 7 days prior to the day of admission. HCD/ED or designee will review all admission paperwork including preliminary plan of care of within 7 days of admission. ED will complete random audits to ensure ongoing compliance.
Standard #:	22VAC40-73-550-G
Description:	Based on the staff and resident record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or staff person. Evidence of this review shall be the resident?s or staff person?s written acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the resident?s or staff person?s record. Evidence: 1.The record for staff #3 contains an annual review of resident?s rights and responsibilities dated 09/30/22. During the onsite inspection the facility provided a written acknowledgement of review of the resident?s rights for staff #3 signed and dated 01/03/24, which is dated more than annually after the previous review of 09/30/22. 2.The record for staff #5 contains an annual review of resident?s rights and responsibilities dated 05/06/21. During the onsite inspection the facility provided a written acknowledgement of review of the resident?s rights for staff #5 signed and dated 01/03/24, which is dated more than annually after the previous review of 05/06/21. 3.The record for resident #8 contains an annual review of resident?s rights and responsibilities dated 03/08/22. During the onsite inspection the facility provided a written acknowledgement of review of the resident?s rights for resident #8 signed and dated 01/04/24, which is dated more than annually after the previous review of 03/08/22.
Plan of Correction:	Resident rights will be reviewed with all residents/staff annually and audited by the LED and BOM to ensure that all rights have been reviewed and signed. ED will complete random audits to ensure ongoing compliance.
Standard #:	22VAC40-73-940-A
Description:	Based on the record review and staff interview the assisted living facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: 1. The facility?s record contains an annual fire inspection completed on 01/06/22. The facility does not have documentation of an annual fire inspection completed after 01/06/22. Staff # 4 acknowledged the facility?s record of the last fire inspection completed is dated 01/06/22.
Plan of Correction:	Facility Admin will ensure that the annual fire inspection has been/will be completed in a yearly / timely manner. The facility will keep a record on file.
Standard #:	22VAC40-73-980-A
Description:	Based on review of the facility?s first aid kit the facility failed to ensure a complete first aid kit shall be on hand in each building at the facility, located in a designated place that is easily accessible to staff but not to residents. Items with expiration dates must not have dates that have already passed. The kit shall include: Gauze pads and roller gauze, waterless hand sanitizer or antiseptic towelettes, triangular bandages, and tweezers. Evidence: 1. During review of the first aid kit with staff #2 the following items were not included in the first aid kit: roller gauze, waterless hand sanitizer or antiseptic towelettes, triangular bandages, and tweezers.
Plan of Correction:	The community will ensure that all items in the first aid kit are present and items with expiration dates are not past their expiration date. The community will create a spreadsheet and assign care manager on duty and/or designee to check first aid kit supplies and expiration dates monthly and to notify the Executive Director of any supplies out of compliance