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: 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 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 22VAC40-80 COMPLAINT INVESTIGATION

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: An unannounced complaint 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. A complaint was received by VDSS Division of Licensing on 01/02/2024 regarding allegations in the areas of: Staffing and Supervision, and Resident Care and Related Services. 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: 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 investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint 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 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 #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medications shall 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. The facility?s medication management plan provided during the onsite inspection and dated 02/2018 documents ?medications should be given within 1 hour on either side of the specified times.? 2. Resident?s #1 medication administration record (MAR) for Jan. 2024 documents scheduled times of 8:00 am for Nuedexta and a Lidocaine Patch to be administered and 9:00 am for the following medications to be administered: Aspirin, Vitamin DC, Metoprolol, Entresto and Omeprazole. On 01/03/24 at 10:40 am during the onsite medication pass observation, the Licensing Inspector (LI) observed staff #5 administer the following medications to resident #1: Nuedexta, Lidocaine Patch, Aspirin, Vitamin DC, Metoprolol, Entresto and Omeprazole. 3. Resident?s #1 Order Chart Report documents the resident?s medications were administered to the resident more than one hour after the scheduled time on the following dates and times: 01/01/24, Nuedexta, schedule for 8:00 pm, and administered 01/02/24 @ 12:22 am. 01/02/24, Lidocaine Patch scheduled for 8:00 am and administered at 11:02 am; 01/02/24, Nuedexta scheduled for 8:00 am and administered at 11:02 am. 4. Resident?s #3 Jan. 2024 MAR documents the following medications are scheduled to be administered at 9:00am: Acidophilus, Diltiazem, Divalproex, DOK Soft gel, Eliquis, Finasteride, Fluticasone, Furosemide, Metoprolol, Pantoprazole, Quetiapine, Slow-release Iron, Tamsulosin, and Vitamin D3. Resident?s #3 Order Chart Report documents the resident was administered the above listed medications more than one hour after the scheduled time on 01/03/24 at 11:13 am. 5. Resident?s #4 Jan. 2024 MAR documents Gabapentin is scheduled to be administered to the resident at 8:00 am. The resident?s order report documents Gabapentin was administered to resident #4 more than one hour after the scheduled time on 01/04/24 @ 10:53 am. 6. Resident?s #4 MAR documents the following medications are scheduled to be administered @ 9:00 am: Ibuprofen, Acidophilus, Cetirizine, Multivitamins, omeprazole, polyethylene, pravastatin, and vitamin D3. Resident?s #3 Order Chart Report documents the resident was administered the above listed medications more one hour after the scheduled time on 01/04/24 at 10:53 am.
Plan of Correction:	To prevent recurrence, Health Care Director or Designee will review for timely administrations on daily basis for next 6 weeks and skills observations every six months of all RMAs