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: May 7, 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 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 05/07/2024 from 9:07 am to 4:36 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/03/24, 04/09/24, 04/17/24, 04/25/24, 04/28/24, and 05/06/24 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the safe secure unit, and assisted living unit was completed, and a review of the medication cart. Lunch was observed. 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 allegation?s 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 dated 02/2018 documents ?medications should be given within 1 hour on either side of the specified times.? 2.The facility?s ?Orders Charted Report? documents resident #1 received their Insulin Aspart 100 units more than 1 hour after the scheduled time of 7:30 am on the following dates and times: 04/24/24 @ 12:38 p.m. 04/27/24 @ 9:40 a.m. 3.The facility?s ?Orders Charted Report? documents resident #1 received the following 8:00 am medications more than 1 hour after the scheduled time on the date of 04/24/24 at the time of 12:38 p.m.: Acetaminophen, alprazolam, dicyclomine, fluoxetine, metformin, pregabalin, and promethazine. 4.The facility?s ?Orders Charted Report? documents resident #2 received the following 8:00 am and 9:00am medications more than 1 hour after the scheduled time on the date of 04/24/24 at the time of 12:19 p.m.: Eliquis, ensure liquid, amiodarone, breo- ellipta, bumetanide, quetiapine fumarate, and sertraline.
Plan of Correction:	All RMAs and licensed nurses will be re-educated by the HCD/HSD on the proper procedure for documenting the specific reason a medication was administered late before June 1, 2024. Administration times will be reviewed by the HCD/HSD on a weekly basis to determine if changes to administration times are required for specific residents, or if staff assignments require adjustment to allow them to complete the medication pass in a timely manner. The HCD/HSD will review the medication administration policy with all RMAs and licensed nurses every six months. The Pharmacy Manual will also be reviewed in relation to the procedure for ordering medications. The HCD/HSD will complete a medication pass observation on all medication aides and licensed nurses once every six months, or more often if deemed necessary based on the results of the audit. All RMA?s and licensed nurses will continue to follow Harmony Standards.
Standard #:	22VAC40-73-930-B
Complaint related:	Yes
Description:	Based on the staff interview the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. During an interview with staff #3, staff # 3 confirmed the signaling device was not working in the assisted living facility during the dates of 04/29/2024 to 05/02/2024.
Plan of Correction:	The signaling device system has been working properly since May 2, 2024. The Maintenance Director completed a pendant check on all resident pendants to ensure they were working properly.