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: 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: 07/02/2024 from 10:45 AM to 01:00 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 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: 0 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 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 in accordance with physician?s or other prescriber?s orders. EVIDENCE: 1. On 06/28/2024, LI received a written self-report from staff 1 which reported the discovery of a medication omission by staff 2 for resident 1?s scheduled 08:00 PM medications on 06/25/2024. 2. The written self-report, dated 06/28/2024, indicates that resident 1 did not receive her 08:00 PM dose of TYLENOL, BUSPIRONE, CARVEDILOL, and TRAZODONE on 06/25, and when staff 2 was reviewing the dashboard near the end of her shift, that staff member realized that resident 1?s medications were not given at 08:00 PM. When staff 2 went to resident 1?s room to administer the medications, resident 1 was already asleep and ?did not wake? to take her medications. 3. While LI was in the facility for follow up on 07/02/2024, a most current signed medication list was located for resident 1, dated 04/15/2024, which includes the following medications: BUSPIRONE HCL 10 MG QID for Anxiety; CARVEDILOL 6.25 MG BID for HTN; TRAZODONE 50 MG QHS for Insomnia; and TYLENOL 325 MG BID for Pain. 4. Also, during LI?s on-site follow up on 07/02, staff 1 provided a printout of a text message conversation with staff 2, from 06/26/2024, in which staff 2 admits that resident 1 did not receive her nighttime medications the night before because staff 2 had forgotten to give them to resident 1 at the scheduled time and upon remembering that they had not been given it was after 11:00 PM, so staff 2 did not want to go in and wake up resident 1. 5. The June 2024 medication administration record (MAR) for resident 1 indicates that the ACETAMINOPHEN 325 MG, BUSPIRONE HCL 10 MG, CARVEDILOL 6.25 MG, and TRAZODONE 50 MG tabs were not given by staff 2 on 06/25 at 08:00 PM and contains exception notes of PATIENT REFUSED MEDICATION. 6. Alternately, per LI?s interview with staff 1, staff 2 had confessed in a text message that she had forgotten to give the medications to resident 1 at 08:00 PM on 06/25 and did not want to wake up the resident, so resident 1 had not actually refused her medication, instead the medication was omitted by staff 2.
Plan of Correction:	An in-service was held on 6/28/24 to re-educate all clinical staff on the importance of following the MAR and making proper notifications. A medication refresher course was held on 7.9.24 for all clinical staff. The Clinical Specialist, Healthcare Director or designee will ensure 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) shall contain all required components, including any medication errors or omissions. EVIDENCE: 1. The written self-report, dated 06/28/2024, indicates that resident 1 did not receive her 08:00 PM dose of TYLENOL, BUSPIRONE, CARVEDILOL, and TRAZODONE on 06/25, and when staff 2 was reviewing the dashboard near the end of her shift, that staff member realized that resident 1?s medications were not given at 08:00 PM. When staff 2 went to resident 1?s room to administer the medications, resident 1 was already asleep and ?did not wake? to take her medications. 2. During LI?s on-site follow up on 07/02, staff 1 provided a printout of a text message conversation with staff 2, from 06/26/2024, in which staff 2 admits that resident 1 did not receive her nighttime medications the night before because staff 2 had forgotten to give them to resident 1 at the scheduled time and upon remembering that they had not been given it was after 11:00 PM, so staff 2 did not want to go in and wake up resident 1. 3. The June 2024 medication administration record (MAR) for resident 1 indicates that the ACETAMINOPHEN 325 MG, BUSPIRONE HCL 10 MG, CARVEDILOL 6.25 MG, and TRAZODONE 50 MG tabs were not given by staff 2 on 06/25 at 08:00 PM and contains exception notes of PATIENT REFUSED MEDICATION. 4. Alternately, per LI?s interview with staff 1, staff 2 had confessed in a text message that she had forgotten to give the medications to resident 1 at 08:00 PM on 06/25 and did not want to wake up the resident, so resident 1 had not actually refused her medication, instead the medication was omitted by staff 2.
Plan of Correction:	An in-service was held on 6/28/24 to re-educate all clinical staff on the importance of following the MAR and making proper notifications. A medication refresher course was held on 7.9.24 for all clinical staff. Clinical Specialist, Healthcare Director or designee will ensure a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
Standard #:	22VAC40-73-680-J
Description:	Based on record review and staff interview, the facility ailed to ensure that in the event of an adverse drug reaction or a medication error, the following applies: Action shall be taken as directed by a physician, pharmacist, or a poison control center; the resident?s physician of record and family member shall be notified as soon as possible; and medication administration staff shall document actions taken in the resident?s record. EVIDENCE: 1. On 06/28/2024, LI received a written self-report from staff 1 which reported the discovery of a medication omission by staff 2 for resident 1?s scheduled 08:00 PM medications on 06/25/2024. 2. The written self-report, dated 06/28/2024, indicates that resident 1 did not receive her 08:00 PM dose of TYLENOL, BUSPIRONE, CARVEDILOL, and TRAZODONE on 06/25, and when staff 2 was reviewing the dashboard near the end of her shift, that staff member realized that resident 1?s medications were not given at 08:00 PM. When staff 2 went to resident 1?s room to administer the medications, resident 1 was already asleep and did not wake to take her medications. 3. The same written self-report indicates that for actions taken in response to the medication error/omission incident, the facility re-educated employee on the RMA curriculum & DSS guidelines, and personnel action was issued. 4. During LI?s on-site follow up on 07/02, staff 1 indicated that there were no progress notes or other documentation that could verify that resident 1?s physician was notified of the medication error/omission, nor any documentation of guidance received as a result of the medication error/omission.
Plan of Correction:	An in-service was held on 6/28/24 to re-educate all clinical staff on the importance of following the MAR and making proper notifications. Clinical Specialist, Healthcare Director or designee will ensure a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.