VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Memory Care
4414 Pheasant Ridge Road
Roanoke, VA 24014
(540) 685-4900

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: April 16, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/16/2024 from 10:00 AM until 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 04/05/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 23 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding its methods to ensure that each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. EVIDENCE: 1. The facility?s medication management plan (MMP), revised 02/2018, point 12 states ?nurses and RMA?s shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered?. Medications will be re-ordered by: faxing re-orders directly to the pharmacy or placing a call to the pharmacy?. Point 13 of the MMP states ?if a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician instructions will be documented on the (E)MAR?. 2. The March and April 2024 MARs for resident 1 indicate that the following 08:00 AM meds were not given from 03/28 through 04/02 and then not given on 04/04 due to waiting on the pharmacy: AMLODIPINE 5 MG, CERTAVITE (CENTRUM SILVER), FAMOTIDINE 20 MG RISPERIDONE 0.25 MG, VITAMIN D3. 3. The March and April 2024 MARs for resident 1 indicate that the following 06:00 PM meds were not given from 03/29 through 04/04 due to waiting on the pharmacy: DONEPEZIL 10 MG, SIMVISTATION 20 MG. 4. An interview with staff 1 on 04/16/2024 revealed that staff 2 contacted him on 03/27 or 03/28 about the medications for resident 1 being in low supply. Staff 1 reported that he told staff 2 to contact the pharmacy to request refills for those medications; however, there is no documentation that staff 2 contacted the pharmacy to re-order medications at any time. 5. An interview with staff 4 on 04/16 revealed that the medications were only re-ordered on 04/04 when staff 2 notified staff 4 that the resident did not have her medications from 03/28 through 04/04. Staff 4 indicated during the interview with LI, and on the incident report, that the nurse practitioner was notified of the resident?s missed doses; however, this contact and subsequent instructions were not documented on the MAR for resident 1 as required by the facility?s medication management plan.
Plan of Correction:	The RMA team members will be re-educated regarding the community medication management plan to ensure that timely ordering and re-ordering of medications is done properly so that there are no missed doses or interruptions in the medication being administered. The RMA team members will also be re-educated about the proper process for notification to the physician in the event that a medication is not available to administer for any reason and that this notification is to be documented in the electronic MAR. The re-education for the RMA?s will be completed by May 31, 2024. The health care director or designee will be responsible to audit the MAR randomly for 4 residents each week for the next 90 days to ensure compliance with the medication management plan. Weekly medication cart audits/Electronic MAR audits will be conducted by the health care director or designee each week to ensure that the medications ordered are being stored on the carts and that the medications stored on the carts match the electronic MAR for each resident.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained a signed medication list with the following medication orders: AMLODIPINE BESYLATE 5 MG TAB ? TAKE ONE TABLET BY MOUTH EVERY DAY FOR HYPERTENSION; CERTAVITE SR-ANTIOXIDANT TAB ? TAKE ONE TABLET BY MOUTH EVERY DAY FOR SUPPLEMENT; DONEPEZIL HCL 10 MG TAB ? TAKE ONE TABLET BY MOUTH AT BEDTIME FOR DEMENTIA; FAMOTIDINE 20 MG TAB ? TAKE ONE TABLET BY MOUTH EVERY DAY FOR GERD; RISPERIDONE 0.25 MG TAB ? TAKE 1 TABLET BY MOUTH ONCE DAILY FOR MOOD; SIMVASTATIN 20 MG TAB ? TAKE ONE TABLET BY MOUTH AT BEDTIME FOR CHOLESTEROL; VITAMIN D3 1,000 UNIT SOFTGEL ? TAKE ONE CAPSULE BY MOUTH EVERY DAY FOR SUPPLEMENT. 2. The March and April 2024 MARs for resident 1 indicate that the following 08:00 AM medications were not given from 03/28 through 04/02 and then not given on 04/04: AMLODIPINE 5 MG, CERTAVITE (CENTRUM SILVER), FAMOTIDINE 20 MG RISPERIDONE 0.25 MG, VITAMIN D3. 3. The March and April 2024 MARs for resident 1 indicate that the following 06:00 PM medications were not given from 03/29 through 04/04: DONEPEZIL 10 MG, SIMVISTATION 20 MG. 4. Interviews with staff 1 and staff 4 on 04/16 confirmed that these medications were not given to resident 1 between 03/28 through 04/04 because the medications were not in the facility.
Plan of Correction:	The RMA team members will be re-educated regarding administration of medications per physician orders. The RMA team members will also be re-educated about the proper process for notification to the physician in the event that a medication is not available to administer for any reason and that this notification is to be documented in the electronic MAR. The re-education for the RMA?s will be completed by May 31, 2024. The health care director or designee will be responsible to audit the MAR randomly for 4 residents each week for the next 90 days to ensure compliance with medication administration per physician orders. Weekly medication cart audits/Electronic MAR audits will be conducted by the health care director or designee each week to ensure that the medications ordered by the physician are being stored on the carts and that the medications stored on the carts match the electronic MAR for each resident.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) was completed with all required components, specifically regarding any medication errors or omissions. EVIDENCE: 1. The March and April 2024 MARs for resident 1 indicate that the following 08:00 AM medications were not given from 03/28 through 04/02 and then not given on 04/04: AMLODIPINE 5 MG, CERTAVITE (CENTRUM SILVER), FAMOTIDINE 20 MG RISPERIDONE 0.25 MG, VITAMIN D3. 2. Alternately, on the April 2024 MARs for resident 1, those same medications for resident 1 were documented on 04/03 as being given by staff 2; however, interviews with staff 1 and staff 4 on 04/16 confirmed that these medications actually were not given to resident 1 on 04/03 because the medications were not in the facility from 03/28 through 04/04.
Plan of Correction:	The RMA team members will be re-educated to ensure that the electronic MAR is completed/documented with all required components, specifically regarding any medication errors or omissions. The RMA team members will also be re-educated about the proper process for notification to the physician in the event that a medication is not available to administer for any reason and that this notification is to be documented in the electronic MAR. The re-education for the RMA?s will be completed by May 31, 2024. The health care director or designee will be responsible to audit the MAR randomly for 4 residents each week for the next 90 days to ensure compliance with proper documentation for medication errors and omissions. Weekly medication cart audits/Electronic MAR audits will be conducted by the health care director or designee each week to ensure that the medications ordered by the physician are being administered properly and that any medication errors or omissions are being documented appropriately.