Bellaire at Stone Port

Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/27/2024 from 11:00 am to 3:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6/24/2024 regarding allegations in the area(s) of: Resident Care and resident abuse. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 7 Observations by licensing inspector: n/a Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: ¿Yes¿

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: 05/06/2024 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: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: 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 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Date of Inspection: February 14, 2024 Type of Inspection: Complaint inspection Standards Investigated: As stated above Complaint was determined: Valid If you have any questions, please do not hesitate to contact me at (540) 680-9469 or sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection, you can find the information on the internet: www.dss.virginia.gov The Administrator and the Licensing Inspector discussed the risk assessment ratings for the violations for this inspection.

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/31/2023 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 regarding allegations in the areas use of chemical restraints, abusiveness toward a specific resident, failure to properly screen staff. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed an observation of of the memory care unit. Number of resident records reviewed/interviewed: 1 Number of staff records reviewed/interviewed: 6 plus/5 Observations by licensing inspector: Residents in memory care were engaged. There were no outward signs of oversedation. Further review of all medication administration records showed no documentation of overuse of medication and very little if any of PRN medication beyond Tylenol. The cart showed no signs of medication misuse. Additional Comments/Discussion: The resident named in the complaint who allegedly was verbally abused by a staff person said, during her private interview, that no such thing occurred. She further indicated she was the one who was loud and instigated the interaction to which the staff remained calm throughout. She said she later apologized to both that staff ember and the administrator for creating a scene in common space. As for screening staff the facility does what is required in the standards and an unscheduled drug screen before hiring. This licensing inspector does not have the expertise to determine if their screening tool is adequate but questions to law enforcement indicate it is a tool often used and appears effective when it is an unscheduled screening. The complainant did not include contact information to obtain a specific individual they felt were being chemically restrained or specific staff that potentially should have an alternative drug tests and the justification for that allegation. Without that additional information the allegations regarding chemical restraints or insufficient staff screening could not be substantiated. The allegation of verbal abuse by a staff member toward a resident was found invalid based on the resident’s interview. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can 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. 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 Sharae Henderson, Licensing Administrator at (804) 726-7833 or by email at sharae.henderson@dss.virginia.gov

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/31/2023 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 7/26/23 regarding allegations in the areas of inappropriate sexually oriented behavior on the part of a staff person. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed an observation of the alleged perpetrator interacting with residents including the resident in question. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: interviews or statement reviews with 7 individuals. Observations by licensing inspector: No inappropriate interaction was observed. Additional Comments/Discussion: In addition to reviewing statements and interviews, video of the staff person in question interacting with the resident was also reviewed. The video showed any physical contact had the walker between them. It was noted that a discussion had been had with the alleged perpetrator regarding previous concerns related to attention for a specific resident and that staff was uncomfortable with her rubbing his back. That appeared to have stopped as per statements and video review. Findings from from the APS investigation done on 7/28 were also reviewed as they had been sent to the licensing inspector. The complainant did not include contact information to obtain a specific date or time that should be reviewed so this inspector along with APS reviewed the most current video available. At this time the allegation of inappropriate sexual contact cannot be substantiated. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. An exit meeting was conducted to review the inspection findings. 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 Sharae Henderson, Licensing Administrator at (804) 726-7833 or by email at sharae.henderson@dss.virginia.gov

Consider adding receipt of copy to actual service plan. Combine personal data or use one form with required information – complete all or mark N/A. Make sure the name gets on each page of the physical form in case it gets separated.

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: 7/31/23 The Acknowledgement of Inspection form was signed and left at the facility for date of the inspection. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. The building was clean and odor free. No housekeeping carts left unattended as noted in a previous inspection. Number of resident records reviewed: 7 Number of staff records reviewed: 6 plus one private duty as that was a violation previously. Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Previous violations were reviewed and noted to be corrected. Outside oversights were current and required action had been taken based on recommendations. The pharmacy review form was noted to the standard requirements as a checklist on the form. Postings were current and observed to be followed. Postings included staff with CPR/First Aid and resident rights. Meals were observed served as per dietary instructions. A diet board is posted in kitchen and updated as applicable. Residents had no complaints. Med cart was organized and scheduled count was correct. Medication was being passed at the time of cart review. Staff have iPads for immediate documentation of rounds. Resident and staff records were in order. Additional Comments/Discussion: Health – 5/23/23 Fire – 8/1/22 with inspection anticipated in August 2023 (will contact when completed) Fire and emergency drills were documented with variation in times on all shifts. Two complaints were also reviewed during this inspection process and documentation can be found in a separate report. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

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: 8/25/2022 from approximately 12:40 pm to 1:40 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 8/23/2022 regarding allegations in the areas of: staff and smoking Number of residents present at the facility at the beginning of the inspection: 65 Number of staff records reviewed: 2 Number of interviews conducted with staff: 5 + 1 collateral An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations regarding staff of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Answered questions and discussed the following topics: 1. Health care oversight, which facility does monthly, must include all residents within a year (one resident record reviewed had not been reviewed for a year). 2. Recommended training record completed in the Relias program be signed by staff at least every six months as there is no electronic signature process in place. 3. Resident council meeting minutes may include the actions taken instead of sending a separate letter – as long as copies continue to be issued prior to the next meeting. 4. Reviewed the standards for private duty aides and discussed the current process and what needs to be added. 5. Reviewed the sex offender registry standards and explained the process to complete checks prior to admission do not need to be reviewed annually with residents – only information about the sex offender registry. 6. Ensure a section for corrective actions taken is added to the model fire drill form being used. Note: There were no documented problems noted on any fire drills reviewed. 7. Staff were signing that rounds were completed but need to do so each hour conducted in a timely manner for each resident. 8. Discussed the tuberculin form that was recently sent out to all providers and answered questions.

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: 8/22/2022 from approximately 8:55 am to 6:45 pm, 8/23/2022 from approximately 8:15 am to 5:30 pm, 8/24/2022 from approximately 8:20 am to 12:40 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: 65 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 (including one discharge) + select sections of 6 additional records Number of staff records reviewed: 5 + 9 private sitters + 2 volunteers + select sections of 3 additional staff records Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medication administration, medication cart audits, required postings, memory care and assisted living units and activities. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

The licensing inspector for Bellaire at Stone Port conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 4/20/2022. Interviews were conducted with residents and staff relating to the allegation of neglect and falsifying documentation. Resident and staff records, call bell logs and services checklists were reviewed. The information gathered during the investigation does not support the allegation, so the complaint is determined to be “not valid.” One violation, not related to the complaint, was found in the area of individualized service plans not being signed. If you have any questions, contact your licensing inspector at (540) 430-9258.

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 3/31/2022. Interviews were conducted with staff and a resident relating to allegations of abuse and staff not documenting an incident in the resident's record. Resident records were also reviewed. Based upon the information gathered during the investigation, the allegation of abuse was "not valid." Based upon the information gathered, however, the allegation of an incident not being documented in the resident's record was determined to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected " for the violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258

An unannounced monitoring inspection was conducted on 3/8/2022 from approximately 10:00 am to 12:15 pm to follow up on a previous violation of insufficient staffing on the memory care unit. A tour was immediately conducted to observe staffing of the secured and assisted living units. There were 21 residents in care on the secured unit and five staff on duty. There were 48 residents in care on the assisted living unit and six staff on duty. Staff schedules were reviewed and interviews were conducted with residents and staff. There were no violations as a result of this inspection.

Reviewed the staffing standards for memory care, discussed the current residents needs regarding two person assists and discussed increasing staffing on both the memory care and assisted living units to three staff at a minimum. Administrator will notify the licensing inspector if there is ever a staffing shortage.

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 1/19/2022. Interviews were conducted with residents and staff relating to allegations of insufficient staffing. Staff schedules were also reviewed. The information gathered during the investigation supports the allegation, so the complaint is determined to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected" for the violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258.

Notify the licensing inspector, prior to work being started, of the specific repairs that will need to be completed. Also, continue to update the licensing inspector as work progresses and when all repairs have been completed.

An unannounced monitoring inspection was conducted on 1/21/2022 in response to the facility reporting a sprinkler had burst. A tour was conducted of the facility and the affected areas. Interviews were also conducted with staff and residents. The information gathered during the inspection determined no violations with applicable standards or law.

An unannounced monitoring inspection was conducted on 1/21/2022 in response to a previous violation related to resident care. Interviews were conducted with residents and staff. Staff were observed assisting residents and conducting activities. The information gathered during the inspection determined no violations with applicable standards or law.

An unannounced non-mandated monitoring inspection was conducted on 12/7/2021 from approximately 1:15 pm to 4:30 pm in response to an incident of staff to resident abuse that was reported to the licensing office on 11/28/2021. Staff and resident records, staff schedules, training, qualifications and criminal record reports were reviewed. Interviews were also conducted with staff and the resident involved. The area of non-compliance was in personal care services. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions contact your licensing inspector at (540) 430-9258.

A non-mandated monitoring inspection was initiated on 9/13/2021 and concluded on 9/13/2021. The administrator was contacted by telephone to conduct the inspection in the area of self-administered medications. The administrator reported the current census was 69. The licensing inspector emailed the administrator a list of documentation required to complete the inspection. The licensing inspector conducted a virtual inspection on 9/13/2021. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Recommendations discussed with the director of health and wellness: 1. Attach the list of medications in the stat box directly onto the outside rather than keeping it in a separate area. 2. Director of health and wellness and executive director attend the individualized service plan and uniform assessment instrument training again since it has been a while since they were completed. 3. Do not bunch the ambulation activities of daily living all together - each needs to be addressed separately. 4. Even though hospice services were listed on the ISP, ensure the information is very specific to each service provided. 5. Having all medication aides document the insulin information the same way. All information was documented; however, one medication aide was documenting the information differently than the others.

A renewal inspection was initiated on 7/23/2021 and concluded on 7/29/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 66. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed four resident records, four staff records, one additional resident and one additional staff record, two contract staff records, activities calendar, menu, fire drills, staff schedules, health care oversight, dietary reviews, medication administration records, physicians' orders, as well as other information submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/28/2021. An exit interview was conducted with the director of health and wellness on the date of inspection and on 7/29/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.