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: June 11, 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: 06/11/2024 from 11:00 AM until 02:00 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 05/28/2024 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: 90 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: 2 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 #:	22VAC40-73-680-D
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. On 05/28/2024, LI was notified by staff 1 of a medication error over the weekend prior, which was discovered through a medication administration audit. On 06/02/2024, LI received a follow up written report from staff 1 which indicated that an audit discovered that on 05/25/2024, the morning dose of Lacosamide for resident 1 was omitted (not given). The report also indicated that resident 1?s physician and daughter were notified and that there were no negative reactions observed as a result of the missed dose. 2. The record for resident 1 contained signed orders for LACOSAMIDE 150 MG TAB - Take 1 tab by mouth twice daily for seizures, effective 04/09/2024. 3. The May 2024 medication administration record (MAR) for resident 1 indicated that on 05/25/2024, the medication LACOSAMIDE 150 MG TAB was not administered at 08:00 AM with a reason noted by staff 2 of ?patient unable to take medication?. 4. An interview with staff 1 revealed that when staff 2 was questioned about the missed dose on the morning of 05/25, staff 2 admitted that resident 1 was physically able to take the medication, but staff 2 could not find the LACOSAMIDE 150 MG TAB for resident 1 in the medication cart at the 08:00 AM medication pass. Staff 2 had later been notified that this medication is kept in the narcotics box.
Plan of Correction:	Staff 2 has been removed from employment at Harmony 7-3-24. Staff 2 has been reported to the BON. Medication refresher course has taken place 7-9-24 for current staff. Healthcare Director or designee will be responsible to ensure that a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) contained all required information, specifically documentation of any medication errors or omissions. EVIDENCE: 1. The May 2024 MAR for resident 1 indicated that on 05/25/2024, the medication LACOSAMIDE 150 MG TAB was not administered at 08:00 AM with a reason noted by staff 2 of ?patient unable to take medication?. 2. An interview with staff 1 revealed that when staff 2 was questioned about the missed dose on the morning of 05/25, staff 2 admitted that resident 1 was physically able to take the medication, but staff 2 could not find the LACOSAMIDE 150 MG TAB for resident 1 in the medication cart at the 08:00 AM medication pass. Staff 2 had later been notified that this medication is kept in the narcotics box; however, the May 2024 MAR was never updated with an accurate reason to reflect the reason for medication omission that was made by staff 2.
Plan of Correction:	Staff 2 has been removed from employment at Harmony 7-3-24. Staff 2 has been reported to the BON. Medication refresher course has taken place 7-9-24 for current staff. Healthcare Director or designee will ensure that a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.