VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Memory Care
4414 Pheasant Ridge Road
Roanoke, VA 24014
(540) 685-4900

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Oct. 14, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Technical Assistance:

450-C

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 10/14/2020 and concluded on 01/04/2021. A complaint was received by the department regarding allegations in the areas of resident care and supervision. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the healthcare director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-E
Complaint related:	Yes
Description:	450-E Based on record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. EVIDENCE: 1. The ISP for resident 2, which contained identified needs that were dated for July 2020, did not contain a date and signature of the licensee, administrator, or his designee, nor did it contain a date and signature of the resident or his legal representative.
Plan of Correction:	An updated care plan with signatures will be completed upon resident 2 returning to the facility. The Executive Director/Designee will be responsible for ensuring that care plans will be reviewed for accuracy and signatures prior to filing in the resident record.
Standard #:	22VAC40-73-550-C
Complaint related:	Yes
Description:	550-C Based on record review, the facility failed to ensure that any resident of an assisted living facility has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia, one of which is being free from degrading or demeaning acts against him. EVIDENCE: 1. On 2/17/2020, a representative on behalf of resident 1 provided confirmation to executive facility staff that a camera device will be in use in the room belonging to resident 1 due to concerns of unexplained damage to personal property from suspected bodily fluids in the resident?s laundry hamper and trash can, and the camera device will be used in compliance with facility policy at that time and state and federal law. 2. On 4/8/2020 at 6:20 PM, resident 2 was observed on camera entering the room of resident 1 and then toileting herself in the trash can next to resident 1 while she was sleeping. 3. On 4/26/2020 at 7:14 AM, resident 2 was observed on camera entering the room of resident 1 and then toileting herself in the laundry hamper belonging to resident 1. 4. On 6/6/2020 during the hours of 12:00 AM ? 5:00 AM resident 2 was observed on camera entering the room of resident 1 and then toileting herself in the closet belonging to resident 1. 5. On 6/13/2020 at 6:03 AM, resident 2 was observed on camera entering the room of resident 1 and then toileting herself in the trash can belonging to resident 1. Then, resident 2 was observed on camera wiping herself with an article of clothing belonging to resident 1. 6. On 7/2/2020 at 11:36 PM, resident 2 was observed on camera entering the room of resident 1 and then toileting herself in the trash can next to resident 1 while she was sleeping. 7. On 7/27/2020 at 3:35 PM, a still photo was taken by a representative of resident 1 of the appearance of fecal matter on a throw rug belonging to resident 1.
Plan of Correction:	The family of resident 2 was interviewed to determine possible cause of pattern. Resident 2 was relocated in September 2020 to another room conducive of her home travel pattern. The Healthcare Director/Designee will ensure that the resident's patterns will be monitored to ensure appropriateness.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	930-D Based on record review, the facility failed to ensure that for each resident with an inability to use a signaling device, that daily rounds shall be made and documented as specified by the resident?s individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 1, dated 6/23/2020, indicated that the resident will need at least two hour safety rounds due to her inability to use the call bell system. 2. The two hour round check log for resident 1 ranging from 12/31/2019 at 12:00 AM to 10/13/2020 at 10:00 PM did not contain entries for the following dates and times: ? January 16 and 17 from 12:00 AM through 10:00 PM ? February 14 from 8:00 AM through 2:00 PM ? February 15 from 12:00 AM through 6:00 AM ? February 17 from 12:00 AM through 6:00 AM and 4:00 PM through 10:00 PM ? February 21 at 2:00 PM ? February 24 from 12:00 AM through 6:00 AM and 8:00 PM through 10:00 PM ? February 27 from 4:00 PM through 10:00 PM ? March 4 from 6:00 PM through 10:00 PM ? March 6 at 4:00 PM ? March 13, March 14, March 15, and March 16 from 12:00 AM through 6:00 AM only ? March 20 from 12:00 AM through 6:00 AM ? March 22 through March 23 from 12:00 AM through 10:00 PM ? April 1 from 4:00 PM through 10:00 PM ? April 3 from 12:00 AM through 6:00 AM and 4:00 PM through 6:00 PM ? April 4 from 4:00 PM through 10:00 PM ? April 5 from 12:00 AM through 6:00 AM ? April 6 from 2:00 AM through 6:00 AM ? April 9 through April 18 from 12:00 AM through 10:00 PM each day ? May 15, May 16, and May 31 from 12:00 AM through 10:00 PM each day ? June 1 from 12:00 AM through 10:00 PM ? June 15 at 10:00 PM ? June 30 from 12:00 AM through 10:00 PM ? July 1 from 8:00 PM through 10:00 PM ? July 14 through July 31 from 12:00 AM through 10:00 PM each day ? August 3 through August 6 and August 13 through August 14 from 12:00 AM through 10:00 PM each day ? August 26 from 8:00 AM through 2:00 PM ? August 30 from 4:00 PM through 10:00 PM ? September 1, September 14, and September 15 from 12:00 AM through 10:00 PM ? September 16 from 12:00 PM through 2:00 PM ? September 22 from 8:00 AM through 4:00 PM ? October 2 from 4:00 PM through 10:00 PM 3. The most current ISP for resident 2, undated, indicated that the resident will require safety rounds at least every two hours due to inability to use the call system. 4. The two hour round check log for resident 2 ranging from 12/31/2019 at 12:00 AM to 10/13/2020 at 10:00 PM did not contain entries for the following dates and times: ? January 1 at 6:00 AM ? January 6 at 10:00 PM ? January 7 at 12:00 PM and 2:00 PM ? January 17 from 8:00 AM through 2:00 PM ? January 18 from 12:00 PM through 2:00 PM ? January 20 at 6:00 AM ? February 2 from 12:00 AM through 6:00 AM ? February 5 from 8:00 PM through 10:00 PM ? February 15 from 12:00 AM through 6:00 AM ? February 17 from 12:00 AM through 6:00 AM and 4:00 PM through 10:00 PM ? February 21 at 2:00 PM ? February 24 from 12:00 AM through 6:00 AM and 8:00 PM through 10:00 PM ? February 27 from 4:00 PM through 10:00 PM ? February 28 at 10:00 PM ? March 4 from 6:00 PM through 10:00 PM ? March 6 at 4:00 PM ? March 13, March 16, March 20, and March 25 from 12:00 AM through 6:00 AM each day ? April 1 from 4:00 PM through 10:00 PM ? April 3 from 12:00 AM through 6:00 AM and 4:00 PM through 6:00 PM ? April 5 and April 6 from 12:00 AM through 6:00 AM each day ? April 7 from 2:00 AM through 6:00 AM and 4:00 PM through 10:00 PM ? April 8, April 11, and April 12 from 12:00 AM through 10:00 PM each day ? April 24 from 4:00 PM through 10:00 PM ? May 15, May 16, May 25, and May 31 from 12:00 AM through 10:00 PM each day ? June 1 and June 6 from 12:00 AM through 10:00 PM each day ? July 1 from 8:00 PM through 10:00 PM ? July 14 through July 31 from 12:00 AM through 10:00 PM each day (See attachment for additional evidence)
Plan of Correction:	Staff was trained on the call system and provisions for rounds to be made for residents with the inability to use the signaling device. The Shift Supervisor and Healthcare Director will ensure that round sheets will be reviewed for accuracy and completion.