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: April 16, 2024

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint 59244 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 05/15/2024 from 11:00 AM until 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/15/2024 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: 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 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 #:	22VAC40-73-130-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. EVIDENCE: 1. The Code of Virginia ? 63.2-1606-A #1 states that any person licensed, certified, or registered by health regulatory boards shall make suspected abuse, neglect, or exploitation reports to the local department or the adult protective services hotline. 2. The record for staff 5 reveals that this individual is a licensed healthcare professional. 3. Progress notes that were entered by staff 5, on 01/18/2024, indicate that staff was notified that resident 1 was going to the front desk and making accusations that money was being stolen from her by her responsible party and that she needed a ride to the bank. The progress notes also indicate that resident 1 has had this behavior in the past and as a result, her responsible party was notified, and the resident was ?settled and at lunch?. 4. Interview with staff 1 revealed that there is no confirmation that staff 5 reported to adult protective services the concerns presented by resident 1 of possible financial exploitation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed for a significant change in a resident?s condition. EVIDENCE: 1. The progress notes for resident 1, dated 03/31/2022, reference her care plan being completed in conjunction with her responsible party; however, the record for resident 1 does not contain this care plan or ISP, nor does it contain any ISP. 2. Interviews with staff 1 and staff 3 revealed that they cannot locate any ISP for resident 1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding methods to ensure that medications are filled and refilled in a timely manner to avoid missed doses. EVIDENCE: 1. The medication management plan for the facility, with a revised date of 02/2018, section 5. (g.) states that ?RMAs will complete and document a medication cart audit for their medication carts weekly.? Section 12 states that ?nurses and RMAs 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 delivered?. 2. The record for resident 1 contains signed physician?s orders for CHOLESTYRAMINE LIGHT PACKET, effective 02/28/2023, to MIX 1 PACK IN 4-6 OUNCES OF WATER AND DRINK ONCE DAILY FOR CHOLESTEROL. 3. The April 2024 MAR for resident 1 indicates that the CHOLESTYRAMINE LIGHT PACKET was not given on 04/09, 04/10, 04/12, 04/15, and 04/16 due to awaiting pharmacy delivery. 4. Progress notes by staff 4 on 04/12/2024 for resident 1 indicate that the resident did not receive her CHOLESTYRAMINE LIGHT supplement packet due to it not being on the cart and staff 4 accidentally clicked (on the MAR) as administered on 04/12 instead of not administered. The same progress note also acknowledges that the family provides the medication, per Express Care. 5. Progress notes by staff 4 on 04/15/2024 for resident 1 indicate that a voicemail was left on the resident?s responsible party?s phone by two staff members at 09:24 AM to let her know that the resident has ran out of her Cholesterol packets, seven days after the CHOLESTYRAMINE was first noted to be out.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that medications are administered according to physician?s or other prescriber?s orders. EVIDENCE: 1. The record for resident 1 contained signed physician?s orders for LIDOCAINE 5% PATCH, effective 03/09/2024, to APPLY 1 PATCH TO AFFECTED HIP DAILY FOR PAIN. 12 HOURS ON, 12 HOURS OFF. 2. On 04/14/2024 at 04:58 PM, LI received photo evidence of resident 1 wearing two patches at the same time, one was located above her right-side waistline (to the side on her lower back) and the other was located below her right-side waistline (in the gluteal region). 3. Interview with staff 3 revealed that she was aware that resident 1 was discovered with two patches on recently and said that sometimes resident 1 wants her patch placed on her lower back and it?s possible that the medication staff member who applied the second patch did not see the first patch because it was underneath her clothes, below her waistline, not on her hip as prescribed.
Plan of Correction:	Not available online. Contact Inspector for more information.