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: Feb. 18, 2021

Complaint Related: No

Areas Reviewed:

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

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 monitoring inspection was initiated on 12/30/2020 and concluded on 01/28/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. 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 self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-440-D
Description:	440-D Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required. EVIDENCE: 1. The UAI for resident 1, dated 3/10/2020, indicated that the resident requires only human physical assistance when toileting; however, the ISP, dated 3/10/2020, indicated that the resident requires mechanical assistance of grab bars in addition to human physical assistance. 2. Interview with staff 3 indicated that the ISP most accurately reflects the resident?s toileting needs. 3. The UAI for resident 3, dated 6/10/2020, indicated that the resident has medication administered/monitored by professional nursing staff; however, medications in an assisted living facility are administered/monitored by a lay person.
Plan of Correction:	The UAI for resident 1 and resident 3 was corrected to reflect needs. The Healthcare Director/Designee will ensure that UAIs will be reviewed for accuracy prior to filing in the resident record.
Standard #:	22VAC40-73-460-H
Description:	460-H Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with the activities of daily living (ADLs). EVIDENCE: 1. The UAI, dated 03/10/2020, and the ISP, dated 06/21/2020, for resident 1 indicated that the resident requires physical assistance with the ADLs of bathing, dressing, and toileting, as well being incontinent of bowel and bladder weekly or more. 2. An interview with staff 3 indicated that on 12/24/2020, when she checked on resident 1 at noon, the resident was still sitting upright in her bed with her breakfast tray. 3. An interview with both staff 3 and staff 4 indicated that they had interviewed staff 2, who was assigned to provide care to resident 1 on that day from 7:00 AM until 3:00 PM. During their interview, staff 2 stated that she ?had not been back in the resident?s room to check on her or provide care for the resident and did not let anyone know that she was not going to take care of this resident?. Staff 2 also stated that she ?did not get paid enough to provide care to COVID residents?. 4. The UAI, dated 06/02/2020, and the ISP, dated 06/02/2020, for resident 2 indicated that the resident requires physical assistance with the ADLs of bathing, dressing, toileting, and transferring, as well as being incontinent of bowel and bladder weekly or more. 5. The UAI, dated 06/10/2020, and the ISP, dated 06/10/2020, for resident 3 indicated that the resident requires physical assistance with the ADLs of bathing, dressing, and toileting, as well as being incontinent of bowel and bladder weekly or more. 6. An interview with staff 3 indicated that staff 1 was assigned to provide care to residents 2 and 3 on 12/22/20 during 3:00 PM and 7:00 PM. When staff 3 contacted staff 1 via text message on 12/23/20 to ensure that she will be working her shift on that date, staff 1 texted back that she ?could not care for COVID residents due to having two small children at home?. Staff 3 also indicated that staff 1, referring to her assigned residents, also texted and said that she had ?picked up that shift with the intentions of not dealing with them, and I didn?t touch them last night.?
Plan of Correction:	Staff 1 and Staff 2 was terminated immediately. The Administrator/Healthcare Director will ensure that staff are trained on caring for COVID-19 residents.
Standard #:	22VAC40-73-930-D
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 06/21/2020, indicated that the resident will need at least two hour safety rounds due to her inability to use the call bell system. The two hour round check log for resident 1 for 12/24/2020 did not contain entries for the following times: ? 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, ? 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM 2. The ISP for resident 2, dated 06/02/2020, indicated that the resident will need at least two hour safety rounds due to his inability to use the call bell system. The two hour round check log for resident 2 for 12/22/2020 did not contain entries for the following times: ? 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM 3. The ISP for resident 3, dated 06/10/2020, indicated that the resident will need at least two hour safety rounds due to his inability to use the call bell system. The two hour round check log for resident 3 for 12/22/2020 did not contain entries for the following times: ? 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, ? 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM
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.