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: July 2, 2024

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint # 59806 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2024 from 10:45 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 06/28/2024 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: 1 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 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 #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that medications are administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. At 08:39 AM on 06/28/2024, LI received a complaint that resident 1 was transported to a local emergency department (ED) as a result of medication staff finding her with blood on her pillow and altered mental status that morning. 2. Hospital visit documentation indicates that resident 1 displayed seizure activity in the emergency department at approximately 09:57 AM on 06/28. The same documentation contains the following physician statement at 10:14 AM: ?Was in provider area when nursing around the corner informed of patient in status epilepticus. Unsure of exact time of start of seizure, but when I came around corner 2 EMS personnel had patient on L side. Nursing requested abortive medications. Ativan 2 mg ordered verbally. Turned NC O2 up from 0.5 LPM to 6 LPM, obtained portable suction and EMS personnel suctioned patient while Ativan administered. Seizure broke. Would estimate total time I witnessed between 1-2 minutes but unclear of exact time of start of seizure.? The same physician notes later state that ?patient is supposed to be on Lacosamide 150 MG BID but unclear per son whether she had gotten any last night or this morning but he suspects that she may not have had either.? 3. The hospital ED provider notes from 10:17 AM on 06/28/2024 indicate that the resident presented to the emergency room complaining of reported seizure; the onset of symptoms was unknown; and EMS advised that patient apparently missed her nighttime dose of her seizure medicine, LACOSAMIDE 150 MG. The same notes also indicate that resident 1?s presenting condition was attributed to medication non-compliance. 4. At 11:44 AM on 06/28, LI received notification that the physician on duty at the local ED had confirmed with the ALF by phone that staff 1 did not give resident 1 her anti-seizure medication (LACOSAMIDE 150 MG) at 09:00 PM on 06/27, despite staff 1 having indicated on the MAR that the LACOSAMIDE 150 MG was given to resident 1 at 09:00 PM on 06/27. (See attached page for additional evidence)
Plan of Correction:	Staff 1 has been removed from employment. Staff 1 has been reported to the BON. Medication refresher course has taken place 7.9.24 for current staff. Healthcare Director or designee will complete a 10% audit of the MAR each day looking for omissions and pharmacy errors.
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall contain all required components, including any medication errors or omissions. EVIDENCE: 1. At 08:39 AM on 06/28/2024, LI received a complaint that resident 1 was transported to a local emergency department (ED) as a result of medication staff finding her with blood on her pillow and altered mental status that morning. 2. The hospital ED provider notes from 10:17 AM on 06/28/2024 indicate that the resident presented to the emergency room complaining of reported seizure; the onset of symptoms was unknown; and EMS advised that patient apparently missed her nighttime medications including her seizure medicine, LACOSAMIDE. The same notes also indicate that her presenting condition was attributed to medication non-compliance. 3. At 11:44 AM on 06/28, LI received notification that the physician on duty at the local ED had confirmed with the ALF by phone that staff 1 did not give resident 1 her anti-seizure medication (LACOSAMIDE 150 MG) at 09:00 PM on 06/27, despite staff 1 having indicated on the MAR that the LACOSAMIDE 150 MG was given to resident 1 at 09:00 PM on 06/27. 4. On 06/28/2024 at approximately 09:23 PM, LI received an incident report from staff 2 which confirmed the events involving resident 1 that were reported to LI in the morning on that same date. The incident also notes that during the facility?s internal investigation of the incident, staff 2 and staff 3 found that the 09:00 PM dose of LACOSAMIDE was omitted on 06/27/2024 by staff 1; however, the MAR was signed by staff 1 to show that the medication was administered along with any other medications due at 09:00 PM. The internal investigation also revealed that the separate controlled drug count sheet was not signed off for the 09:00 PM dose of LACOSAMIDE for 06/27 and that dose was still in the medication card. 5. Interview between LI and staff 2 on 07/02/2024 verified that staff 1 falsified MAR documentation of administering LACOSAMIDE 150 MG at 09:00 PM on 06/27 when it was not actually administered.
Plan of Correction:	Staff 1 has been removed from employment at Harmony 7.3.24. Staff 1 has been reported to the BON. Medication refresher course has taken place 7.9.24 for current staff. Healthcare Director or designee will complete a 10% audit of the MAR each day looking for omissions and pharmacy errors.