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: Dec. 1, 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

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: 12/01/2022 from 08:45 AM until 05:30 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 #:	22VAC40-73-210-B
Description:	Based on record review, the facility failed to ensure that in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. EVIDENCE: 1. The record for staff 2, hired 08/05/2019, contained approximately 12 hours of training between 08/05/2021 ? 08/04/2022. 2. Interviews with staff 5, 6, 7, and 8 could not verify that staff 2 had any additional training for that time period.
Plan of Correction:	What Has Been Done to Correct?: A variety of virtual and in-person training opportunities are completed on hire and offered to staff throughout the year. Staff 2 has been scheduled for required training to be completed. How Will Recurrence Be Prevented?: An audit will be conducted of training records to determine compliance and staff will be held accountable to attend at least 18 hours annually. Person Responsible: Department Manager or designee
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure each direct care staff member received certification in first aid within 60 days of employment. EVIDENCE: 1. The records for staff 3, date of hire 09/13/2022, and staff 4, date of hire 08/24/2022, did not contain evidence of either staff receiving or having current certification in first aid.
Plan of Correction:	What Has Been Done to Correct?: A First Aid & CPR course has been scheduled for any employee who needs to refresh their FA & CPR training. How Will Recurrence Be Prevented?: Training records will be audited to ensure current FA & CPR training certification. Any associate out of compliance will be given a deadline to complete. Person Responsible: Business Office Manager or designee
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review, the facility failed to ensure a direct care staff member was trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The record for staff 3, date of hire 09/13/2022, did not contain documentation that the direct care staff person received training prior to working with residents in methods of dealing with residents with aggressive behaviors. 2. A facility reported incident was received by LI on 10/13/2022, which indicated that resident 7 pushed resident 13 down in the hallway on 10/12/2022. 3. A facility reported incident was received by LI on 11/30/2022, which indicated that resident 1 pushed residents 16 and 17 down to the floor on that same date. 4. Interviews with staff 5, 6, 7, and 8 could not verify that staff 3 has received aggressive behavior training as of the date of inspection.
Plan of Correction:	What Has Been Done to Correct?: An aggressive/expressive behaviors training has been scheduled. Audit personnel files to see who is out of compliance Set date and time for training to be completed. How Will Recurrence Be Prevented?: Aggressive/expressive behaviors training will be provided upon initial orientation of new team members. New associates must complete training prior to work on floor. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-270-4
Description:	Based on record review, the facility failed to ensure that direct care staff receive annual refresher training for aggressive or restrained residents. EVIDENCE: 1. The record for staff 2 did not contain documentation of aggressive behavior training which included demonstration techniques. 2. Interviews with staff 5, 6, 7, and 8 could not verify that staff 3 has received annual refresher aggressive behavior training.
Plan of Correction:	What Has Been Done to Correct?: An aggressive/expressive behaviors refresher training has been scheduled for any staff needing to refresh their skills. Audit all personnel records to determine who is out of compliance. Once that is determined classes will be set up to complete. How Will Recurrence Be Prevented?: Refresher training opportunities will be offered annually and as needed to ensure staff receive a refresher course. Person Responsible: Executive Director or designee; BOM and specific department manager
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 after a fall. EVIDENCE: 1. The record for resident 3 contained progress notes on 11/01/2022 at 03:00 AM indicating that resident 3 was found on the floor mat beside his bed and was found to have bruising on his lower left leg. At 06:40 AM, notes indicate that resident 3 was checked for signs or symptoms of pain or discomfort after the previous fall. 2. The most current fall risk rating in the record for resident 3 was dated 07/11/2022.
Plan of Correction:	What Has Been Done to Correct?: The fall risk rating for Resident 3 has been updated. How Will Recurrence Be Prevented?: An audit will be conducted of fall risk ratings to ensure compliance. Staff reeducation to be provided to ensure understanding. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure a comprehensive service plan (ISP) for a resident contained all identified needs. EVIDENCE: 1. The ISP for resident 4 contained a physician?s order, dated 10/05/2022, for a mechanical soft diet to be prepared and served to the resident; however, the ISP for the resident, dated 03/30/2022, did not contain the aforementioned information Also, the record for resident 4 contained a physician?s order, dated 11/01/2022, for the resident to be evaluated for physical and occupational therapy services. 2. Interview with staff 5 revealed that resident 4 is receiving therapy services; however, the ISP did not contain the aforementioned information.
Plan of Correction:	What Has Been Done to Correct?: Individualized Service Plan for Resident 8 has been updated. How Will Recurrence Be Prevented?: ISP?s will be audited to ensure all identified needs are addressed. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the licensee administrator, or his designee. EVIDENCE: 1. The ISP for resident 4, dated 03/30/2022, did not contain the signatures of the licensee, administrator, or designee nor a signature from the resident or the resident?s legal representative. 2. The ISP for resident 7, dated 03/23/2022, did not contain the signature of the resident or the resident?s legal representative. 3. The ISP for resident 8, dated 03/09/2022, was not signed by the licensee, administrator, nor person who developed the plan.
Plan of Correction:	What Has Been Done to Correct?: Current, signed ISP was located, signed and filed in chart for Residents 4 and 8. How Will Recurrence Be Prevented?: An audit will be conducted to ensure all ISP?s are signed by the appropriate individuals and placed in the resident record. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-470-F
Description:	Based on observation, resident record review and staff interview, the facility failed to ensure that medication attention from a licensed health care professional was secured immediately when a resident suffers a serious medical condition or there is reason to suspect that such has occurred and the circumstances involved and the medical attention received or refused was documented in the resident?s record as well as the date and time of occurrence and the personnel involved was documented as well. EVIDENCE: 1. Facility direct care staff progress notes for resident 13 indicate the following: 11/01/2022 at 9:35AM ? resident right leg is leaking fluid. Resident has been digging in skin redirected by staff. Will continue to monitor. 11/03/2022 at 6:50AM ? resident leg is still leaking. 11/03/2022 at 12:17PM ? Collateral 2 notified of bilateral lower extremity weeping. 11/08/2022 at 11:42AM ? resident?s leg was seeping, resident continually picks at right leg. 11/17/2022 at 7:48AM ? resident legs are still leaking. Supervisor notified 11/17/2022 at 10:27AM ? notified collateral 2 of continuous weeping in BLE. Awaiting return call. 11/19/2022 at 8:30PM ? an incident had occurred between the resident and another resident. When staff look over resident, staff noted ?Resident complained of pain to BLE; swelling, redness and open areas noted to legs, not new issues, already being addressed? 11/22/2022 at 2:01AM ? resident send [sic] out because of her legs hurting family notified 11/23/2022 at 8:42PM ? resident legs still look bad but no adverse reaction from the ABX on this shift. 11/25/2022 at 9:58PM ? resident legs continue to weep with edema present. Pedal pulse present, not warm to touch with slight blanching and no discomfort or pain observed. This nurse cleansed, dried and bandaged area. Will continue to monitor. 11/29/2022 at 3:53PM ? referral sent to collateral 3 for legs. Per Collateral 3, they are awaiting insurance approval. 2. The record for resident 13 contained a physician?s order, dated 11/17/2022, that the purpose of the visit for the resident was weeping legs. The physician prescribed anti-biotics for seven days and home health skilled nursing to evaluate and treat BLE as indicated and the resident was diagnosed with cellulitis of both legs; however, the facility did not send a referral for skilled nursing services until 11/29/2022. 3. During on-site inspection on 12/01/2022, collateral 1 observed resident 13 in the hallway outside of her room and that the resident was wearing pants that stopped at the top of her knees. Collateral 1 noted that both of the resident?s legs appeared to be very red and weeping fluid. The resident was complaining of her legs bothering her very much and took off her shoes stating that her feet were bothering her as well. 4. During the on-site exit interview on 12/01/2022, staff 5 revealed that the facility did not have documentation that the resident had medical attention secured immediately by a licensed health care professional after the 11/01/2022 and 11/03/2022 staff documentation of the resident?s legs leaking fluid until the physician?s order dated 11/17/2022.
Plan of Correction:	What has been done to correct?: Resident 13 was sent to the hospital for evaluation and treatment and has transferred to rehab. Re-educate staff to notify and follow-up as directed with medical professional when medical attention is required and to utilize emergency medical services when required. How will recurrence be prevented?: Clinical nurse will audit all residents on a weekly basis who require medical attention to ensure proper follow up has occurred Person responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-640-A
Description:	Based on an audit of the facility?s medication carts, resident record review and staff interview, the facility failed to implement portions of its medication management plan. EVIDENCE: 1. The facility?s medication management plan states, ?Nurses and RMAs shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered?. Medications will be re-ordered by: faxing re-orders directly to the pharmacy or placing a call to the pharmacy?? 2. While observing a medication pass for resident 10 on the date of inspection, staff 1 stated that resident 10 would not be receiving the following medication: THERA TEARS 0.25% EYE DROPS ?INSTILL 1 DROP INTO BOTH EYES EVERY MORNING FOR DRY EYES? because the medication was out and had to be re-ordered. The medication had not arrived as of the date of inspection. As a result, resident 10 missed the administration of her THERA TEARS on the date of inspection. 3. The facility?s medication management plan indicates that narcotics and other controlled substances will be counted shift to shift between the on-coming and off-going medication staff, and direct staff to staff hand off of the keys to the medication carts will take place after a correct inventory has been documented. 4. The controlled medication count records for October and November 2022 for medication cart 100/300 contained multiple dates that did not include the signature of either the on-coming staff or the off-going staff. 5. The facility?s medication management plan indicates that nurses and medication aides are responsible for ensuring that all medications, including over-the-counter, supplements and or samples are in the original packaging, undamaged and used within the appropriate date of use, or expiration. The Healthcare Coordinator will periodically audit the medications to ensure that all medications meet the standards included in the medication management plan one of which the Healthcare Coordinator will check for expired or discontinued medications and any other activities to ensure the safe practices of administering medications. 6. The 100/300 hall medication cart contained a plastic bag of liquid Lorazepam Intensol in prefilled syringes for resident 14. Its attached pharmacy sticker label on the plastic bag indicated that the aforementioned medication was delivered to the facility on 07/20/2022 and the labels on the individual syringes included a date of 07/20/2022. The plastic bag also included a ?Refrigerate? sticker and a sticker that stated ?Date vial expires 10/20/2022?. 7. The manufacturer?s instructions for liquid Lorazepam Intensol indicate that the medication must be stored at a cold temperature (refrigerate at 2 degrees Fahrenheit to 8 degrees Fahrenheit) and to discard the opened bottle after 90 days. It was discussed during the on-site exit interview on 12/01/2022 that the syringes are filled from a bottle of liquid Lorazepam Intensol. The controlled drug record for the resident for the medication included documentation that the resident was last administered this medication on 11/30/2022.
Plan of Correction:	What has been done to correct?: Resident 10 medications were received from the pharmacy. Expired medications have been removed from med carts. Weekly audit to be conducted on all med carts to ensure medication carts meets standards. How will recurrence be prevented?: Medication cart audit tool to be reviewed by nurse on a weekly basis Person responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a medication cart audit, the facility failed to ensure medications remained in the pharmacy issued container until administered to the resident. EVIDENCE: During the medication cart audit of the 100/300 medication cart, collateral 1 noted four loose pills in the second drawer (two white round pills, one white oblong pill and one light yellow oblong pill), one loose pill in the third drawer (one white oblong pill), and one loose pill in the fourth drawer (one white oblong pill).
Plan of Correction:	What Has Been Done to Correct?: Additional medication storage carts have been ordered to allow for less crowded storage of the pill cards in each drawer. How Will Recurrence Be Prevented?: Medication Storage Cart audits will occur routinely to ensure that no loose pills are in the carts. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-680-D
Description:	Based on observation, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident 8 requires a blood sugar check three times a day before meals and with the following parameters: ?INJECT SUBCUTANEOUSLY PER SSI: 151-200 = 4U; 201-250 = 6U; 251-300 = 8U; 301-350 = 10U; 351-400 = 12U; 401-500 = 14U; 501-600 = 16U; NOTIFY MD IF BS > 300. 2. The October 2022 MAR for resident 8 indicated the following: At 05:00 PM on 10/07/2022, BS=220 and 4U given; at 12:00 PM on 10/14/2022, BS=300 and 10U given; at 05:00 PM on 10/17/2022, BS=407 and 12U given; at 08:00 AM on 10/18/2022, BS=227 and 8U given; at 12:00 PM on 10/19/2022, BS=352 and 10U given; at 12:00 PM on 10/21/2022, BS=255 and 10U given. 3. The October 2022 MAR for resident 8 indicated blood sugar readings greater than 300 on the following dates: 10/01, 10/02, 10/06, 10/10 - 10/12, 10/14, 10/15, 10/17 ? 10/20, 10/25, and 10/27 - 10/31; however, there is no documentation which indicates that staff notified the resident?s doctor.
Plan of Correction:	What Has Been Done to Correct?: Medication staff have been reeducated on following provider orders. Resident 8 medication orders were reviewed to ensure proper instructions match the medication label and MAR. Additional documentation requirement has been added to the MAR for documenting notification to provider of any results outside of the given parameters. How Will Recurrence Be Prevented?: Consistent and ongoing review of audits on a weekly basis by nurse to ensure compliance. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and be documented. EVIDENCE: 1. The record for resident 4 contained a signed physician?s order, dated 11/02/2022, for the resident to have a prothrombin time and international normalized ratio (PT/INR) recheck in three weeks. 2. Interview with staff 5 confirmed that as of 12/01/2022 the resident did not have the aforementioned re-check conducted per the signed physician?s order. 3. The facility?s medication management plan indicates that new orders received by the facility will be transcribed to the Electronic/Medication Administration Record (E)MAR and reviewed by a licensed nurse. During exit interview with facility staff, collateral 1 asked staff 5 if the aforementioned statement would include medication orders and treatment orders for residents and staff 5 stated that is correct. 4. The record for resident 7 contained a physician?s order, dated 11/28/2022, for continuous oxygen two liters per minute via nasal cannula or mask by concentrator or tank; however, neither the November and December 2022 medication administration records nor the treatment administration records contained documentation that the resident has been receiving oxygen.
Plan of Correction:	What Has Been Done to Correct?: Resident 4 PT/INR was checked the day of the inspection. Hospice to provide any further PT/INR orders and the order will be added to the medication administration record. How Will Recurrence Be Prevented?: Regular review of new orders for medications and treatments will take place to ensure compliance. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-680-K
Description:	Based on observation, the facility failed to ensure that PRN medications are only administered by registered medication aides (RMAs) when the facility has obtained from the resident?s physician a detailed medication order which includes symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. The uniform assessment instrument for resident 5, dated 11/10/2022, indicates that he is disoriented to some spheres all the time and requires medication administration/monitoring by RMA/LPN. In addition, resident 5 resides on the Harmony Square (secured unit) due to the diagnosis of dementia with a serious cognitive impairment. 2. The record for resident 5 contained physician?s orders for ALPRAZOLAM 0.25 MG TAB ?TAKE ONE TABLET BY MOUTH THREE TIMES A DAY AS NEEDED FOR AGITATION?; however, it does not indicate the exact time frames the medication is to be given in a 24-hour period, nor does it indicate directions as to what to do if symptoms persist. 3. The September 2022 MAR for resident 5 contains documentation that staff 1 had administered this PRN medication on September 1 and September 3. The October 2022 MAR for resident 5 contains documentation that staff 1 had administered this PRN medication on October 12.
Plan of Correction:	What Has Been Done to Correct?: Resident 5 PRN medication order was clarified with provider to include timeframes and MAR was updated with proper timeframe and instructions for administration. How Will Recurrence Be Prevented?: PRN orders will be reviewed by nurse to ensure that parameters and timeframes are included. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure hazardous materials were stored in a locked area. EVIDENCE: 1. At 8:54AM during on-site inspection, it was noted by collateral 1 and staff 7 that the door to the 300-hall laundry room was unlocked. One of the cabinets in the laundry room was noted to be unlocked as well and contained multiple spray bottles of McKesson dermal wound cleanser and DermaKlenz wound cleanser. The spray bottles contained a warning label to keep out of the reach of children. Another unlocked cabinet in the laundry room contained multiple bottles of Medline lotion which also contained a warning label to keep out of reach of children. 2. At 8:59AM, a spray bottle of Pantene volume texture non-aerosol hairspray was observed on the bathroom counter of resident 15?s room and contained a warning label to keep out of reach of children. 3. At 9:02AM, a spray can of Static Guard was observed on the bathroom counter of resident 14 room and contained a warning label that indicated ?Keep out of reach of children. Use only in well ventilated area. Intentional misuse by deliberately concentrating and inhaling the contents can be harmful or fatal.? 4. At 9:07AM, collateral 1 and staff 6 observed a small round, red pill in the common area which was located outside of room H109. This pill was also observed by staff 5. 5. Also, at 9:17AM, collateral 1 and staff 6 and 7 observed two pills, a round white/red pill that had contained a red coating and half of a light blue pill in resident 4?s bed. 6. Interview with staff 7 confirmed that they were pills in the resident?s bed. The 200/400 medication cart did contain blister packs for Senna Plus and Sertraline HCL for resident 4 which were the same in appearance as the pills found in resident 4?s bed.
Plan of Correction:	What Has Been Done to Correct?: Digital locks were set to automatically lock behind the staff to ensure chemical storage areas remain locked. How Will Recurrence Be Prevented?: Daily reviews of physical plant will occur to ensure hazardous materials are stored appropriately and all storage spaces are locked. Person Responsible: Executive Director or designee
Standard #:	22VAC40-73-930-D
Description:	Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to other services, the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. EVIDENCE: 1. The ISP for resident 3, dated 07/08/2022, indicates that two-hour rounds will be performed to monitor for emergencies or other unanticipated needs due to the inability to use a signaling device. 2. The two-hour round check log for resident 3 did not contain documentation that rounds were made for the resident on the following dates and times: From 12:00 AM through 06:00 AM on 11/14/2022; from 12:00 AM through 06:00 AM on 11/27/2022; and from 12:00 AM through 06:00 AM on 11/28/2022. 3. The ISP for resident 8, dated 03/09/2022, indicates that two-hour rounds will be performed to monitor for emergencies or other unanticipated needs due to the inability to use a signaling device. 4. The two hour round check log for resident 8 did not contain documentation that rounds were made for the resident on the following dates and times: From 12:00 AM through 06:00 AM on 11/21/2022; from 08:00 AM through 02:00 PM on 11/22/2022; from 08:00 AM through 10:00 PM on 11/25/2022; from 12:00 AM through 2:00 PM on 11/26/2022; from 12:00 AM through 06:00 AM on 11/27/2022; from 08:00 AM through 02:00 PM on 11/28/2022; from 12:00 AM through 06:00 AM on 11/29/2022; and 08:00 AM through 02:00 PM on 11/30/2022. 5. The ISP for resident 4, dated 03/03/2022, indicates that the resident will have two-hour rounds performed to monitor for emergencies or other unanticipated needs due to an inability to use a signaling device. 6. The two-hour round check log for resident 4 did not contain documentation that rounds were made for the resident on the following dates and times: 11/15/2022 from 12:00AM through 6:00AM; 11/17/2022 from 12:00AM through 2:00PM and at 10:00PM; 11/18/2022 at 8:00AM; 11/27/2022 from 12:00AM through 6:00AM and 11/28/2022 from 12:00AM through 6:00AM. 7. The ISP for resident 7, dated 03/23/2022, indicates that the resident will have two-hour rounds performed to monitor for emergencies or other unanticipated needs due to an inability to use a signaling device. 8. The two-hour round check for resident 7 did not contain documentation that rounds were made for the resident on the following dates and times: 11/13/2022 from 12:00AM through 6:00AM; 11/22/2022 from 12:00AM through 6:00AM and from 4:00PM through 10:00PM; 11/27/2022 from 12:00AM through 6:00AM and 11/28/2022 from 12:00AM through 6:00AM and from 2:00PM through 10:00PM.
Plan of Correction:	What Has Been Done to Correct?: The documentation for rounds was added to the MAR on 11/30/2022 and medication staff to document as instructed for any resident requiring routine rounds for any resident that requires this. How Will Recurrence Be Prevented?: Medication staff to check this documentation in the MAR each shift. Clinical nurse to monitor rounding documentation weekly. Person Responsible: Clinical Specialist, Healthcare Director or designee
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff 3, date of hire 09/13/2022, did not contain the results of a criminal history record report. 2. Interview with staff 5 confirmed this was accurate.
Plan of Correction:	What Has Been Done to Correct?: All employees receive a criminal background review upon hire. All personnel records will be audit to determine who is out of compliance. How Will Recurrence Be Prevented?: Criminal Background records will be audited to ensure results are received prior to the 30th day of employment. Person Responsible: Business Office Manager or designee