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. 10, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 12/6/2021. The LI reviewed documentation, toured the facility, and conducted interviews relating to allegations of lack of resident supervision and failure to report a resident fall with injury to appropriate parties. The information gathered during the investigation supports part of the allegations. Based on the preponderance of evidence the complaint is determined to be valid. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	70-A Based on record review, the facility failed to ensure that the facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. Facility progress notes for resident 1 which were dated 11/28/2021 and entered by staff 2 on 12/6/2021, indicated that the resident had an unwitnessed fall on the 3:00 PM to 11:00 PM shift, and the resident was looked over by the registered medication aide (RMA) on duty but did not appear to have any signs of physical injury nor any complaints of pain, so she was assisted back to bed; however, facility progress notes for resident 1, dated 11/29/2021 and entered by staff 2 on 12/6/2021, indicated that resident 1 was displaying a hematoma to her forehead which worsened throughout the day. 2. Neither staff 1 nor the licensing inspector were able to locate a facility report from this incident.
Plan of Correction:	The facility Healthcare Director or Health Services Director will ensure that clinical staff will receive additional training on incident reporting to include reporting of major incidents and shift to shift communication record. In order to prevent recurrence, staff will review the communication log and resident charting.
Standard #:	22VAC40-73-460-F
Complaint related:	Yes
Description:	460-F Based on record review, the facility failed to ensure that the facility shall notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. EVIDENCE: 1. Facility progress notes for resident 1 which were dated 11/28/2021 and entered by staff 2 on 12/6/2021, indicated that the family of resident 1 was not notified of her 11/28 fall until 11/30 at 1:00 PM by staff 2.
Plan of Correction:	The facility Healthcare Director or Health Services Director will ensure that staff will receive additional training on incident reporting with emphasis on documenting contacting of responsible party. In order to prevent recurrence, staff will review incident reporting documentation to ensure it includes reporting to the responsible party and licensure bodies.