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 3/12/24, 03/13/24, 03/19/24, and 3/20/24 regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services 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: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 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 #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure care provision and service delivery shall be resident centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. Resident?s #1 call bell logs for the month of March, April, and May 2024 documented the facility did not promptly respond to the resident?s pendant alert system on the following dates and times: 03/16/24, wait time (1 hr. and 29 mins.) 03/17/24, wait time (5hrs. and 54 mins.) 03/18/24, wait time (3 hrs. and 27 mins.) 03/20/24, wait time (2 hrs. and 06 mins.) 03/30/24, wait time (1 hr. and 34 mins.) 04/03/24, wait time (1 hr. and 50 mins.) 04/06/24, wait time (1 hr. and 07 mins.) 04/12/24, wait time (2 hrs. and 02 mins.) 04/17/24, wait time (1 hr. and 06 mins.) 04/18/24, wait time (2 hrs. and 46 mins.) 04/20/24, wait time (4 hrs. and 11 mins.) 04/22/24, wait time (2 hrs. and 34 mins.) 05/02/24, wait time (2 hrs. and 08 mins.) 05/04/24, wait time (2 hrs. and 08 mins.) 05/04/24, wait time (6 hrs. and 30 mins.) 05/06/24 wait time (1 hr. and 03 mins.) Resident?s #1 UAI and ISP documents the resident needs physical assistance with bathing, dressing, toileting, transferring, eating/feeding, wheeling and mobility. 2. An adult protective services investigation for resident #1 documents the following: ?the client was never put to bed and was left in the lazy boy all night and was found on the floor by the 7am staff this morning, 03/17/24;? ?there is sufficient evidence to show that resident #1 was neglected, resident #1 was found on the floor by morning staff, and documentation provided shows pendant was pushed multiple times on the date of the incident.? Resident?s #1 call bell log documents the resident?s pendant was pushed on the night of 03/16/24 and the morning of 03/17/24 at the following times: 03/16/24 @ 11:15 p.m. 03/17/24 @ 2:13 a.m. 03/17/24 @ 3:09 a.m. 03/17/24 @ 3:18 a.m. 03/17/24 @ 3:48 a.m. 03/17/24 @ 7:57 a.m. 3. Resident?s #2 call bell logs for the month of March, April, and May 2024 documented the facility did not promptly respond to the resident?s pendant alert system on the following dates and times: 05/05/24, wait time (1 hr. and 4 mins.) Resident?s #2 UAI and ISP documents the resident need physical assistance for bathing, and dressing.
Plan of Correction:	The ED/ designee will audit call bell response times daily for the next 30 days and monitored on an ongoing basis as a part of the community?s daily stand up meeting. Any response times outside of CAHV standards will be addressed immediately. Findings will be reported to the Health Care Director for follow-up as needed.