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 23, 2024

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint 59983 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/23/2024 from 10:00 AM until 12:00 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 07/18/2024 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: 91 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: 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 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 #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that the method of communication to keep direct care staff informed on all shifts of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions, shall be included in the records of the involved residents. EVIDENCE: 1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained documentation from a local hospital?s Emergency Department (ED) that the resident was transported by local EMS from the ALF to the hospital on 04/18 with abdominal issues and to be retested for a UTI due to increased confusion; however, the facility?s staff progress notes do not contain documentation that the resident was transported to this local ED with complaints of abdominal issues and increased confusion. 2. Upon being given an opportunity to locate, staff 1 and 2 revealed that this specific documentation for resident 1 did not exist.
Plan of Correction:	Staff have been instructed to communicate all incidents of significant happenings or problems by the end of each shift via progress notes per resident. A 10% random chart audit will be conducted each month for the next three months to determine compliance. HCD will be responsible to ensure successful implementation of the plan of correction.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated at least annually; when the condition of a resident changes; and after a fall. EVIDENCE: 1. On 04/05/2024, LI received an incident report from staff 3 which reported that resident 1 had a fall with injury on the same date and was transported to the local hospital for medical evaluation, and results revealed a right wrist fracture and a urinary tract infection. Staff progress notes by staff 4, dated 04/06/2024, confirm the information from the self-report. 2. Progress notes by staff 4, dated 04/09/2024, indicate that staff 4 had responded to resident 1?s call for assistance on that same date and discovered that resident 1 had fallen earlier that day and had a skin tear to the right elbow. This LI has no documentation that the 04/09 fall had been self-reported by the facility. 3. During the on-site complaint follow up on 07/23/2024, LI requested to review all fall risk ratings on file for resident 1. The fall risk ratings that were provided by staff 1 and staff 2 were dated 04/09/2024, 01/01/2024, and 10/03/2022. Staff 1 and staff 2 indicated that there was no documentation of a fall risk rating update for resident 1?s 04/05/2024 fall.
Plan of Correction:	The fall risk has been updated for resident 1. Staff has been educated as to the importance of updating the fall risk rating. HCD is responsible to ensure successful implementation of the plan of correction.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) is completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. EVIDENCE: 1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained a UAI that was last completed on 10/05/2022. 2. Upon being given an opportunity to locate, staff 1 and 2 revealed that a more current UAI for resident 1 did not exist.
Plan of Correction:	The UAI for resident 1 was updated. A 10% random chart audit will be conducted each month for the next three months to determine compliance. The ED will be responsible to ensure successful implementation of the plan of correction.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
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 of a resident?s condition. EVIDENCE: 1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained an ISP that was last completed on 10/03/2022. 2. Upon being given an opportunity to locate, staff 1 and 2 revealed that a more current ISP for resident 1 did not exist.
Plan of Correction:	The ISP for resident 1 was updated. A 10% random chart audit will be conducted each month for the next three months to determine compliance. The ED will be responsible to ensure successful implementation of the plan of correction.
Standard #:	22VAC40-73-680-E
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. EVIDENCE: 1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained signed orders, dated 05/02/2024, for resident 1 to ?wear her brace at all times only removing for hygiene purposes. There is to be no therapy on her right wrist until further evaluation.? 2. An interview with resident 1 and her responsible party on 07/23 revealed that family had obtained the brace for her wrist on 05/02 and brought it to the facility with the signed physician?s orders to be applied, as ordered, on the same day. The interview further revealed that staff 5 had taken the brace and placed it in the bottom drawer of the 3rd floor medication cart on that same day. The responsible party added that it wasn?t until 05/11 that resident 1 was seen wearing the brace, over a week after it was brought to the facility. 3. The May 2024 MARs for resident 1 indicate that the brace was not added to the MAR until 05/09, and there is no documentation that the brace was placed on the resident until the 7 AM ? 3 PM shift on 05/11. After that time, the May 2024 MAR exception notes for resident 1 state ?Brace Not on Rsd? on 05/11 during the 3 PM ? 11 PM shift, and the exception notes on the following dates say that the ?patient refused medication? when the brace should have already been on her arm: 05/17, 05/20, 05/21, 05/22, 05/23, 05/25, 05/26, 05/29. 4. An interview with staff 1 and staff 2 on the date of follow up indicated that there is no documentation which supports that the brace was removed for hygiene purposes and was re-applied or an attempt was made to reapply it on those exception dates.
Plan of Correction:	No correction can be made as this happened in the past. The staff have been educated as to the importance of updating the medical record. HCD is responsible to ensure successful implementation of the plan of correction.