VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Assisted Living
4402 Pheasant Ridge Road
Roanoke, VA 24014
(540) 970-3524

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: March 11, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint # 59014 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2024 from 09:15 AM to 12:45 PM 03/14/2024 from 11:30 PM to 12:30 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 03/08/2024 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: 93 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: N/A Number of interviews conducted with residents: 0 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 allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record review and staff documentation, the facility failed to ensure that each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. On 03/08/2024, staff progress notes for resident 1 indicate that resident 1 had missed the prior six days of VIMPAT 150 MG (LACOSAMIDE 150 MG) for seizures. On the same date, progress notes for resident 1 indicate that resident 1 was observed to have seizure activity at approximately 09:00 AM and her POA/responsible party was notified. As a result, the resident was sent to the hospital by way of EMS for evaluation. 2. On 03/11/2024, LI responded to the facility to investigate this full event due to receiving a complaint; however, this incident was never reported to the LI by the facility even though it was documented by staff 1 on 03/08/2024.
Plan of Correction:	All staff receiving Reportable training on 04/25 & 04/26. All Managers provided Reportable Grid on 04/19/2024 from Campus ED.
Standard #:	22VAC40-73-450-H
Complaint related:	Yes
Description:	Based on record review and staff documentation, the facility failed to ensure that services specified in the individualized service plan (ISP) are provided to each resident. EVIDENCE: 1. The ISP for resident 1, dated 09/06/2023, states that medication will be given to the resident per M.D. orders and assessed for side effects. 2. The same ISP also indicates that staff will alert POA/responsible party, the ISP includes name and phone number, if this resident refuses the LACOSAMIDE medication or if the medication is not given for any reason with the goal of maintaining medication and to ensure safe administration. 3. The March 2024 medication administration record indicates that resident 1 did not receive the medication LACOSAMIDE 150 MG TABLET ? TAKE 1 TABLET BY MOUTH TWICE DAILY FOR SEIZURES (at 09:00 AM & 09:00 PM). According to this MAR, missed doses began at 09:00 AM on 03/03/2024 until resident 1 was hospitalized on the morning of 03/08/2024. The MAR exception notes for those missed dates and times indicated that staff were waiting on the pharmacy for the medication. 4. Progress notes on 03/08/2024 state that resident 1 was observed to have seizure activity at approximately 09:00 AM and her POA/responsible party was notified. As a result, the resident was sent to the hospital by way of EMS for evaluation. Progress notes also indicate on the same day, that the resident?s POA/responsible party contacted the resident?s neurologist, and the new LACOSAMIDE 150 MG TAB prescription was sent to the pharmacy. 5. Progress notes have no indication prior to the 03/08/2024 seizure and hospitalization that the resident?s POA/responsible party had been notified that the LACOSAMIDE 150 MG TAB medication had run out. An interview with the resident?s POA/responsible party also confirmed that she had not been notified that resident 1 had missed her LACOSAMIDE 150 MG TAB medication from the morning of 03/03/2024 through the morning of 03/08/2024.
Plan of Correction:	All ISPs & UAIs for every resident will be reviewed, updated, etc within 60 days which allows time for HCD to complete as well as HCD & Campus ED to sit with families. ISPs & UAIs will be completed on all new admits by the day of move in so care plan is completed and shared with team members for all new residents.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review, staff documentation, and hospital documentation, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. A medication list for resident 1, signed 09/27/2023, contains orders for LACOSAMIDE 150 MG TABLET ? TAKE 1 TABLET BY MOUTH TWICE DAILY FOR SEIZURES. A subsequent psychoactive medication review form, signed 01/12/2024, indicated to continue the current drug regimen indefinitely. 2. The March 2024 medication administration record indicates that resident 1 did not receive the medication LACOSAMIDE 150 MG TABLET ? TAKE 1 TABLET BY MOUTH TWICE DAILY FOR SEIZURES (at 09:00 AM & 09:00 PM) beginning at 09:00 AM on 03/03/2024 until resident 1 was hospitalized on the morning of 03/08/2024. The MAR exception notes for those dates and times that the medication was missed indicated that the missed doses were due to waiting on the pharmacy. 3. On 03/08/2024, staff progress notes for resident 1 indicate that resident 1 had missed six days of VIMPAT 150 MG (LACOSAMIDE 150 MG) for seizures. On the same date, progress notes for resident 1 indicate that resident 1 was observed to have seizure activity at approximately 09:00 AM and her POA/responsible party was notified. As a result, the resident was sent to the hospital by way of EMS for evaluation. 4. Per hospital Emergency Department notes on 03/08/2024 at 10:49 AM, EMS informed ED staff that resident 1 had a seizure the night before and had not had seizure medications since 03/02. Hospital ED notes clarify that resident 1 had not been on the seizure medication due to being unable to contact primary care. Hospital ED notes indicate that resident 1 also had a seizure when EMS arrived at the facility which lasted about one minute. The ED notes also indicate that the POA/responsible party stated that neurology takes care of her seizure medication, and the POA/responsible party was able to contact them quickly. 5. Per the same hospital ED notes, dated 03/08/2024 at 11:42 AM, the attending nurse was made aware by staff of the patient?s possible seizure activity and the nurse responded to the patient?s bedside. The hospital ED notes further state that the patient appeared to be seizing, jaw clamped, snoring and oxygen saturation dropped to the 70s, but patient stopped seizing on her own without medication intervention at that time. 6. Per the hospital after visit summary, dated 03/08/2024, instructions indicated for the patient to return to the ED if multiple seizures occur within 24 hours when not on normal seizure medications.
Plan of Correction:	All RMAs will be put through the RMA refresher course within 30 days. RMAs to receive in-service training to be conducted on 04/25 & 04/26. RMA refresher training will be completed by 06/01/2024.