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: 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 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 self-report was received by VDSS Division of Licensing on 04/03/2024 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: 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 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 portions of its medication management plan specifically regarding 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, 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?. Point 13 of the medication management plan 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 MAR for resident 1 contains orders for LORAZEPAM 0.5 MG TABLET (effective 02/20/2024) to ?Take 1 tablet by mouth every night for anxiety?. The same MAR indicates that the LORAZEPAM 0.5 MG TAB for resident 1 was not given on 03/27, 03/28, 03/30, and 03/31. The March MAR says this is due to waiting on pharmacy. 3. Per interviews with staff 1 and staff 2 on 04/16, the LORAZEPAM was received at the facility late on 3/27 and was stocked on the 3rd floor cart on 3/28, but it was not given until the evening of 3/29 before it disappeared, and doses were missed on 3/30 and 3/31 before staff 1 and staff 2 were notified. 4. The March MAR for resident 1 does not indicate that the resident?s physician was contacted about the outage, nor did it contain any further instructions that were provided by the physician for that time period as per the facility?s medication management plan point 13.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 physicians or other prescriber?s instructions. EVIDENCE: 1. On 04/04/2024, LI received a written incident report from staff 2 regarding a discovery on 03/31/2024 of a missing narcotic card containing 29 LORAZEPAM 0.5 MG tabs for resident 1. 2. The March MAR for resident 1 contains orders for LORAZEPAM 0.5 MG TABLET (effective 02/20/2024) to ?Take 1 tablet by mouth every night for anxiety?. The same MAR indicates that the LORAZEPAM 0.5 MG TAB for resident 1 was not given on 03/27, 03/28, 03/30, and 03/31. The March MAR says this is due to waiting on pharmacy. Per interviews with staff 1 and staff 2 on 04/16, the LORAZEPAM was received at the facility late on 3/27 and was stocked on the 3rd floor cart on 3/28, but it was not given until the evening of 3/29 before it disappeared, and doses were missed on 3/30 and 3/31 before staff 1 and staff 2 were notified.
Plan of Correction:	Not available online. Contact Inspector for more information.