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: March 27, 2023 and April 4, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring - Self reported incident Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/27/2023 from 11:00 AM until 02:00 PM 04/04/2023 from 10:00 AM until 11:00 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/21/2023 regarding allegations in the area(s) of: Elopement of resident with a serious cognitive impairment from a secured unit. Number of residents present at the facility at the beginning of the inspection: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-460-D
Description:	Based on record review and staff interview and documentation the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. EVIDENCE: 1. Resident 1 moved into the memory care facility on 02/28/2023. 2. The form ASSESSMENT OF SERIOUS COGNITIVE IMPAIRMENT for resident 1, dated 02/09/2023, indicated that resident 1 does have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger or protect his/her own safety and welfare. 3. The individualized service plan (ISP) for resident 1, dated 02/27/2023, indicates that resident 1 is dependent with mobility and requires supervision of staff while on any outings outside of the community. The ISP also states that the resident resides on the Harmony Square (Secure Unit) due to dementia and the inability to recognize danger and will be accompanied by family/friends/staff at all times when off the unit. 4. On 03/21/2023 at 10:58 AM, staff 2 emailed a facility incident report to Licensing Inspector (LI) on behalf of staff 1 which reported that resident 1 had eloped from the facility on the night of 03/20/2023. The report stated that the resident was last seen at 07:00 PM in the theater room located inside of the memory care unit, and the resident was not observed in his apartment at 09:50 PM during rounds but a note was found on his bedroom door stating, ?do not disturb ? sleeping?. The report also noted that the resident?s roommate, resident 2, informed staff that resident 1 spoke with him about leaving for the two weeks prior and resident 2 had not notified anyone. The report further stated ?Window noted to be open with screen popped out and window stops removed. Residents bed noted to have pants stuffed with clothing and pillows lined up with pants to appear as though resident was in bed under blanket?. The incident report noted that local police were notified of the missing resident and a community search began. The resident?s guardian was notified who disclosed to staff that he has had previous elopements. 5. An email on 03/22/2023 at 02:48 PM from staff 1 to the LI disclosed that resident 1 was found in Botetourt County near a local shopping center in Cloverdale. Officers from Botetourt stated that resident 1 was found on the side of the road appearing intoxicated. At approximately 09:00 PM, Roanoke City Police were notified of the discovery and the resident was returned to the facility. Per staff 1, resident 1 was interviewed upon his safe return to the facility and he stated that he slept in the woods from 02:00 AM ? 05:00 AM then walked the rest of the way to Cloverdale. Per staff 1, resident 1 was then sent to a local hospital for evaluation. 6. According to online data from Weather Underground, the temperature on the night and early morning of the elopement ranged from 42 degrees Fahrenheit at 09:54 PM (03/20/2023) to 29 degrees Fahrenheit at 06:54 AM (03/21/2023). 7. According to an online Google Maps search, the distance from The Harmony Collection at Roanoke Memory Care to the identified shopping center location is between 15.5 miles to 19.2 miles and takes approximately 05 hours and 12 minutes to walk.
Plan of Correction:	What has been done to correct? Window lock audit done 3/23/2023 to ensure all window locks are in place and locked. How will recurrence be prevented? Window locks will be checked monthly to ensure placement. Person Responsible? Executive Director or designee Date to be corrected: 6/23/2023