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: May 10, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

380, 700

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/10/2022 09:00 AM ? 06:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1070-B
Description:	Based on observation, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. While completing a physical plant tour of the facility on the date of inspection, at approximately 9:50 AM, LI checked to ensure that the door to the Star Beauty Shop was locked; however, LI found the door to be unlocked. 2. Inside of the Star Beauty Shop, LI observed the following potentially harmful objects to residents with a serious cognitive impairment: An electric hair brush, an electric clipper, an electric razor, four electric curling irons, Biolage styling gel, Big Sexy Hair root pump plus hair spray, Aqua Net extra super hold hairspray, Equate dry shampoo, Suave revitalizing shampoo, Fanci-Full instant hair color, Nurture rinse-free body wash and shampoo, Johnson?s head-to-toe wash & shampoo, Clippercide hair clipper spray, Peroxide Multi Surface cleaner and disinfectant, Mane `n Tail and Body shampoo, Barbasol shaving cream, Mary Kay facial cleanser and moisturizer, Calvin Klein Euphoria lotion, Aveeno daily moisturizing lotion, setting lotion, Delon and Mountain falls nail polish removers, Beauty Secrets nail polish dryer, Dial antibacterial hand soap, peppermint sugar scrub, numerous bottles of nail polish, numerous palettes of eye shadow, and cotton balls. 3. At approximately 9:56 AM, LI observed an open bag containing Bare Minerals foundation and eye shadow and Assured daily moisturizing lotion on the sink in room H304. 4. At approximately 10:03 AM, LI observed a box of sidewalk chalk in an unlocked cabinet in a common area room. 5. At approximately 10:04 AM, LI observed an open bottle of Suave body wash in the shower and Arm & Hammer deodorant, Thera Calazinc body shield lotion, Burt?s Bees body lotion, and Secret deodorant in a drawer of the sink for room H208.
Plan of Correction:	Installed self-locking handle on Star Beauty Shop. Installed safety locks on cabinets inside Star Beauty Shop. Educated contractor to place supplies in cabinets when not in use. Secured items in resident locking cabinet. Removed item to Life Enrichment supplies. Secured items in resident locking cabinet. HCD, Maintenance Director, other designated managers will perform daily room inspections to prevent recurrence.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary diagnosis of dementia in a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident?s file. EVIDENCE: 1. The record for resident 7, admitted 10/16/2021, did not contain the licensee, administrator, or designee?s written determination of the justification of placement of resident 7 into a safe, secure environment. 2. The record for resident 4, admitted 03/31/2022, did not contain the licensee, administrator, or designee?s written determination of the justification of placement of resident 4 into a safe, secure environment.
Plan of Correction:	Record for resident 7 and resident 4 were updated to include written determination documentation. To prevent recurrence, ED/Designee will audit new records for accuracy and completion.
Standard #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. EVIDENCE: The record for resident 7, admitted 10/16/2021, did not contain a six month review of appropriateness of resident 7?s continued residence in the special care unit.
Plan of Correction:	Resident 7 record was updated to include six-month review. To prevent recurrence, ED or Designee will ensure that review for continued placement will be scheduled every six months.
Standard #:	22VAC40-73-50-B
Description:	Based on resident record review, the facility failed to obtain written acknowledgment of the receipt of the disclosure by the resident or his legal representative. EVIDENCE: The record for resident 4 did not contain written acknowledgment that the resident or the resident?s legal representative had received a copy of the disclosure statement from the facility.
Plan of Correction:	Disclosure statement was provided to responsible party for resident 4. To prevent recurrence, Executive Director or Designee will ensure that an audit of new resident business records will be completed prior to admission.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. EVIDENCE: The record for staff 4, hired 2/8/2022, did not contain documentation of having first aid training on the date of inspection.
Plan of Correction:	First Aid class held at facility on 5/11/2022. Staff 4 to enroll in first aide prior to 5/31/2022. To prevent recurrence, Business Office Manager/Designee will enroll new hires and audit for completion prior to 60-days of hire.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure that the fall risk rating shall be reviewed and updated at least annually. EVIDENCE: The record for resident 5 contained a most recent annual fall risk rating which was dated 03/06/2021.
Plan of Correction:	The record of resident 5 has been corrected to contain a fall risk. To prevent recurrence, the ED, Healthcare Director, or Designee will ensure that the ISP will be updated on admission and annually as required.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is completed as required. EVIDENCE: 1. The record for resident 4 contained a physician?s order, dated 05/05/2022, that the resident is a two person to chair assist as tolerated and requested by resident. The ISP for the resident, dated 05/05/2022, indicates the resident needs physical assistance with transferring; however, does not indicate that the resident requires two staff to assist in transferring. 2. The record for resident 6 contained signed physician?s orders, dated 10/11/2021, which indicate that resident 6 is prescribed a regular house diet to be used with a divided plate; however, the ISP for resident 6, dated 05/01/2022, did not indicate that the resident requires a use of a divided plate with her regular house diet.
Plan of Correction:	The ISP for resident 4 and resident 6 have been updated. To prevent recurrence, the Healthcare Director, ED, or Designee will review ISP for accuracy.
Standard #:	22VAC40-73-450-E
Description:	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 legal representative. EVIDENCE: 1. The ISP for resident 7, dated 03/31/2022, was not signed by resident 7 nor designee. 2. The ISP for resident 8, dated 03/31/2022, was not signed by resident 8 nor designee.
Plan of Correction:	ISP for resident 7 and 8 have been provided to responsible parties with efforts for completion noted. To prevent recurrence, the Healthcare Director/Designee will ensure that ISP will remain in the pending folder until receipt of signature.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each residents or his legal representative or responsible individual and evidence of this review shall be written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident?s record. EVIDENCE: 1. The record for resident 2 contained a most recent annual resident rights review which was dated 11/27/2020. 2. The record for resident 5 contained a most recent annual resident rights review which was dated 12/15/2020. 3. The record for resident 6 contained a most recent annual resident rights review which was dated 05/08/2021. 4. The record for resident 8 contained a most recent annual resident rights review which was dated 12/09/2020.
Plan of Correction:	Resident Rights have been mailed to responsible party of resident 4 with written acknowledgment to return. To prevent recurrence, the Life Enrichment Director will ensure annual review for all residents will be conducted on the same month. Return receipt roster maintained.
Standard #:	22VAC40-73-650-C
Description:	Based on resident record review, the facility failed to ensure that physician?s or other prescriber?s orders were reviewed and signed by a physician or other prescriber within 14 days. EVIDENCE: The record for resident 3 contained the following documents: ?03/18/2022 - D/C nystatin cream. Start using Hydrogard Silicone cream with each incontinent episode and prn apply 1 application to sacrum. Hospice provided 1 tube to facility? and ?04/11/2022 - D/C wound treatment from 3/15/22 to left elbow. Area healed.?; however, these documents did not contain the signature of a physician or other prescriber.
Plan of Correction:	Hospice was contacted and physician?s signature obtained on orders. To prevent recurrence, Healthcare Director or Designee will ensure that orders will remain in pending binder until signed. Hospice agencies will be notified that their medical directors must sign orders.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container until administered to residents. EVIDENCE: 1. At approximately 9:27AM, collateral 1 observed a white, round pill located in the externally attached compartment of medication cart 1. 2. At approximately 10:11AM during the on-site inspection, both licensing inspectors observed a white, round pill lying on the floor outside of the star beauty shop. This was also observed by the facility administrator. 3. Medication cart 2 contained the following loose pills in the drawers of the cart: two medium size, white pills with 44/104; one white, round pill with 13/30; one oblong, white pill with L612; one round, brown pill with E52; and one orange, round pill with Mylan 351.
Plan of Correction:	Loose medication removed from the cart. To prevent recurrence, Health Care Director or Designee will perform routine cart audits and skills observations.
Standard #:	22VAC40-73-680-C
Description:	Based on resident record review and observation during morning medication pass, the facility failed to ensure that medications were administered no later than one hour after that are ordered for specific times. EVDIENCE: 1. Resident 9 has a signed physician?s order, dated 04/18/2022, for Aspirin 81 MG, Diltiazem, and Buspirone HCL 5MG to be administered at 8:00AM daily. One licensing inspector (LI) observed staff 1 administer these three medications to the resident at 9:36AM. 2. Resident 10 has a signed physician?s order, dated 04/18/2022, for Fiber Laxative Capsule, Vitamin C, Torsemide 10 MG, Methimazole 5 MG, Certavite, Vitamin D3, Cholestyramine pack, Citalopram, and Erythromycin 0.5% drops to be administered at 8:00AM daily. One LI observed staff 1 administer the aforementioned medications to the resident at 9:50AM.
Plan of Correction:	Physician?s order sheets printed for review of administration times with MD. Review of administration of medications and related provisions standards with RMA staff. To prevent recurrence, Health Care Director or Designee will review for timely administrations. And skills observations.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal record history report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff 5, hired 11/05/2021, contained documentation of a criminal record history request dated 11/06/2021; however, the record did not contain a criminal record response as of the date of inspection. 2. The record for staff 6, hired 11/11/2021, contained documentation of a criminal record history request dated 11/11/2021; however, the record did not contain a criminal record response as of the date of inspection.
Plan of Correction:	Criminal history obtained on staff 5 and staff 6. ED or Designee will audit new staff charts to prevent recurrence.