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: July 26, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

A monitoring inspection was initiated on 7/26/2021 and concluded on 7/29/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 38. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility healthcare oversight, fire and emergency drills, health department inspection, and dietician oversight submitted by the facility to ensure documentation was complete submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/28/2021. An exit interview was conducted with the Administrator and Director of Nursing, and Business Office Manager after the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-70-A
Description:	70-A Based on record review, the facility failed to ensure that a report was made to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. Progress notes for resident 2, dated 6/18/2021, indicated that the resident was observed laying on the floor in front of his wheelchair. Staff discovered the resident had a bleeding head injury for which staff applied pressure to attempt to stop the bleeding. As a result, resident 2 was transported to Roanoke Memorial Hospital (RMH) for treatment. An incident report was not received by Licensing regarding this fall with head injury. 2. Progress notes for resident 3, dated 5/1/2021, indicated that the resident tripped over her wheelchair and fell which resulted in a bleeding head injury. As a result, resident 3 was transported to RMH for evaluation. An incident report was not received by Licensing regarding this fall with head injury.
Plan of Correction:	Health Care Director/Designee will ensure Incident Reports will be reviewed and any major incidents will be reported to regional licensing office within 24 hours of any major incident.
Standard #:	22VAC40-73-440-A
Description:	440-A Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) shall be completed whenever there is a significant change in the resident?s condition. EVIDENCE: 1. The UAI for resident 3, dated 5/23/2021, indicated that the resident is abusive/aggressive/disruptive weekly or more with the type of inappropriate behavior listed as ?exit seeking ? becomes disruptive?. 2. Progress notes for resident 3 noted six instances of physically aggressive behavior from resident 3 toward staff members for the following dates: 4/24/2021, 4/27/2021, 5/1/2021, 5/2/2021, 5/21/2021, and 5/28/2021; however, the UAI was not updated to reflect the significant change.
Plan of Correction:	The UAI for resident 3 was updated to reflect the need. Health Care Director/Designee will ensure UAI will be updated with change of condition and reviewed for accuracy prior to filing in the resident's chart.
Standard #:	22VAC40-73-450-F
Description:	450-F Based on record review, the facility failed to ensure that individualized service plans (ISP) shall be reviewed and updated as the condition of the resident changes. EVIDENCE: 1. The ISP for resident 3, dated 5/23/2021, indicated a description of behavior needs as ?disruptive, exit-seeking weekly? with an identified date of 5/23/2021. The ISP also indicated that the description of services to be provided is that staff will redirect resident when exit seeking. 2. Progress notes for resident 3 noted six instances of physically aggressive behavior from resident 3 toward staff members for the following dates: 4/24/2021, 4/27/2021, 5/1/2021, 5/2/2021, 5/21/2021, and 5/28/2021; however, the ISP was not updated to address this significant change from disruptive behavior to physically aggressive behavior.
Plan of Correction:	The ISP for resident 3 was updated to reflect need. Health Care Director/Designee will ensure ISP will be updated with significant change of condition and reviewed for accuracy prior to filing in the resident's chart.
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 the signaling device the individualized service plan (ISP) shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. EVIDENCE: 1. The ISP for residents 1, 2, and 3 indicated that the residents are unable to use the call bell appropriately. The ISP for residents 1, 2, and 3 also indicated that staff will perform frequent checks for safety and incontinence needs; however, no minimal frequency of checks was indicated.
Plan of Correction:	The ISP(s) for resident 1, 2, 3 were updated to reflect every 2 hour rounds. Health Care Director/Designee will ensure that ISP will be reviewed for accuracy prior to filing in the resident's chart.
Standard #:	22VAC40-73-970-A
Description:	970-A Based on documentation review, the facility failed to ensure that fire and emergency drills are completed for each shift in a quarter. EVIDENCE: 1. For the most recent quarter of 2021, fire and emergency evacuation drills were documented to have occurred during first shift on 4/30/21, during first shift on 5/25/21, and during third shift on 6/29/21.
Plan of Correction:	The maintenance director conducted a fire drill for the missing shift. Administrator/Maintenance Director will ensure that TELS will be monitored to ensure that fire drills are conducted on the correct shift monthly.