VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Assisted Living
4402 Pheasant Ridge Road
Roanoke, VA 24014
(540) 970-3524

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Feb. 6, 2024

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 02/06/2024 from 08:45 AM until 03:45 PM 02/08/2024 from 09:00 AM until 01:30 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 #:	22VAC40-73-260-A
Description:	Based on record review and staff interview, 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: 1. The record for staff 3, hired 09/19/2023, contained current basic life support (BLS) certification from American Red Cross; however, a review of the content for the American Red Cross BLS course revealed that this course does not include first aid training. 2. An interview with staff 6 during the inspection revealed that no first aid certification could be found for staff 3.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) contained a description of identified needs based on services being received. EVIDENCE: 1. The record for resident 9 contained physical therapy (PT) service notes which indicated that the resident has been receiving PT services since 09/05/2023; however, the ISP for resident 9, dated 09/18/2023, does not contain any updates to reflect the PT services being provided to resident 9. 2. Staff 6 was unable to locate a more current ISP for resident 9 which contained PT services.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications shall be administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 7 contained a signed medication list, dated 12/26/2023, for TAFLUPROST 0.0015% EYE DROP ? INSTILL 1 DROP INTO RIGHT EYE ONCE DAILY FOR GLAUCOMA. While performing an audit of medication cart 1 on the date of inspection, staff 1 revealed to LI that the TAFLUPROST eye drops were not in the cart because they were waiting on pharmacy delivery. A review of the February 2024 MAR for resident 7 indicated that the TAFLUPROST 0.0015% EYE DROP was not administered to resident 7 on 02/01 and on 02/03-02/08/2024 due to waiting for the pharmacy. 2. An interview with staff 6 revealed that the TAFLUPROST EYE DROP was being stored in the medication refrigerator at the facility, per manufacturer?s instructions, and staff 6 provided LI visual confirmation that the eye drops were in the refrigerator on the date of inspection. Staff 1 was unaware that the TAFLUPROST EYE DROP was being stored in the refrigerator. 3. The record for resident 8 contained signed physician?s orders, effective 10/10/2023, for blood pressure and heart rate checks twice daily and to NOTIFY PROVIDER IF SBP > 170 or DBP >100. 4. The January 2024 MAR for resident 8 indicated the following: On 01/08/2024 on the 3-11 shift, the blood pressure reading was 177/100. On 01/09/2024 on the 7-3 shift, the blood pressure reading was 178/88. On 01/11/2024 on the 3-11 shift, the blood pressure reading was 200/91. On 01/12/2024 on the 3-11 shift, the blood pressure reading was 235/91. On 01/28/2024 on the 7-3 shift, the blood pressure reading was 240/103. 5. In addition, the February 2024 MAR for resident 8 indicated the following: On 02/03/2024 on the 3-11 shift, the blood pressure reading was 178/68. On 02/05/2024 on the 3-11 shift, the blood pressure reading was 178/82. 6. Neither the record nor the progress notes for resident 8 contained documentation that the physician was notified of the blood pressure readings on 01/08, 01/09, 01/11, 01/12, 01/28, 02/03, and 02/05/2024 per the prescribed orders. 7. The record for resident 8 contained a medication list, signed 12/26/2023, for GABAPENTIN CV 100 MG CAPSULE ? TAKE ONE CAPSULE BY MOUTH 2 TIMES A DAY FOR NEUROPATHY; however, the January 2024 MAR for resident 8 indicated that this medication was scheduled and/or given 3 times a day from 01/11/2024 through 01/31/2024. Staff 6 provided a signed physician?s order, effective 01/27/2024, which indicated to give GABAPENTIN 100 MG 3 times a day, but staff 6 was unable to provide signed orders for GABAPENTIN CV 100 MG to be scheduled and/or given 3 times a day from 01/11/2024 until 01/26/2024. 8. The record for resident 10 contained signed physician?s orders for sliding scale insulin effective 09/19/2023. The order indicates: NOVOLOG FLEX PEN 100U/ML INJECT SUBCUTANEOUSLY 3 TIMES A DAY BEFORE MEALS PER SSI: 201-250 = 6U; 251-300 = 8U; 301-350 = 10U; 351-400 = 12U. 9. The January 2024 MAR for resident 10 indicated the following: On 01/01/2024 at 05:00 PM, the blood sugar (BS) reading was 228 and that 8U of insulin were given. On 01/12/2024 at 08:00 AM, the BS reading for resident 10 was 206 and no insulin was given. On 01/19/2024 at 12:00 PM, the BS reading for resident 10 was 255 and 6U were given. 10. Based on the prescribed sliding scale, on 01/01/2024 at 05:00 PM, resident 10 should have received 6U. On 01/12/2024 at 08:00 AM, resident 10 should have received 6U. On 01/19/2024 at 12:00 PM, resident 10 should have received 8U. 11. The February 2024 MAR for resident 10 indicated that on 02/06/2024 at 08:00 AM, the BS reading for resident 10 was 261 and 6U were given; however, based on the prescribed sliding scale, resident 10 should have received 8U on 02/06/2024 at 08:00 AM.
Plan of Correction:	Not available online. Contact Inspector for more information.