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: March 11, 2024 and March 14, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint # 59013 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2024 from 09:15 AM to 12:45 PM 03/14/2024 from 11:45 AM to 12:45 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/08/2024 regarding allegations in the area(s) of: Resident care and related services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 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 some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident care and related services. A violation notice was issued; any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record review, the facility failed to 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. The electronic record for resident 1 contained an incident report which was completed by staff 3 about a medication error that occurred. The report stated that resident 1 was given a discontinued blood pressure medication on 03/05/2024 on the 7 AM ? 3 PM shift. The report further stated that resident 1 was given 2-hour blood pressure checks which had been within normal limits, and the resident?s power of attorney and primary care physician (PCP) were notified. 2. The regional licensing office, and this LI, were not made aware of the medication error until the complaint was received on 03/08/2024.
Plan of Correction:	Staff will be in-serviced on the proper reporting of incidents to the ED and HCD, as Acting ED was not aware of this incident at the time of occurrence. All staff will be in-serviced on reportables.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was updated at least annually. EVIDENCE: 1. During the on-site investigation on 03/11/2024, the record for resident 1 contained an ISP which was dated 08/12/2022. 2. Interviews with staff 1 and staff 2 revealed that a 2023 ISP for resident 1 could not be found.
Plan of Correction:	Clinical Specialist will audit resident ISP?s to ensure compliance and will ensure all ISP?s are up to date and accurate.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that medications were administered according to physician?s orders. EVIDENCE: 1. The record for resident 1 contained signed physician?s orders, dated 08/08/2023, which included the following blood pressure medications: AMLODIPINE BESYLATE 5 MG TAB, take 1 tablet by mouth every day for hypertension; ATENOLOL 25 MG TAB, take 1 tablet by mouth every day for hypertension. 2. The record for resident 1 also contained signed physician?s orders, dated 02/12/2024, which stated to stop AMLODIPINE, STOP ATENOLOL, and START NEBIVOLOL 5 MG. The order further notes that the physician ordered for the AMLODIPINE and ATENOLOL to continue until the NEBIVOLOL 5 MG gets repackaged and sent to the facility, and the order was faxed to the pharmacy on 02/27/2024. 3. Interview with staff 4 on 03/14/2024 revealed that she was working on the 2nd floor medication cart on the morning of 03/05/2024. Staff 4 recalled to LI that she gave two blood pressure medications to resident 1 on the morning of 03/05/2024, one of which was the new blood pressure medication for resident 1 called NEBIVOLOL 5 MG, and the other was a blood pressure medication that had been discontinued; however, staff 4 cannot remember which discontinued BP medication that she had given.
Plan of Correction:	RMA?s will be in-serviced on cart audits and the procedure on new and discontinued medications, as well as proper medication administration practices.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall include any medication errors or omissions. EVIDENCE: 1. The electronic record for resident 1 contained an incident report, completed by staff 3, about a medication error that occurred. The report stated that resident 1 was given a discontinued blood pressure medication on 03/05/2024 on the 7 AM ? 3 PM shift. The report further stated that resident 1 was given 2-hour blood pressure checks which had been within normal limits, and the resident?s power of attorney and primary care physician (PCP) were notified. 2. Interview with staff 4 on 03/14/2024 revealed that she was working on the 2nd floor medication cart on 03/05/2024. Staff 4 recalled to LI that she gave two blood pressure medications to resident 1 on the morning of 03/05/2024, one of which was the new blood pressure medication for resident 1 called NEBIVOLOL 5 MG, and the other was a blood pressure medication that had been discontinued; however, staff 4 cannot remember which discontinued BP medication that she had given. 3. The March 2024 MAR for resident 1 indicates that at 09:00 AM on 03/05/2024, the date of the medication error, that only the NEBIVOLOL 5 MG TAB was given to resident 1 for hypertension despite the admission of staff 4 that a discontinued blood pressure medication was also given at 09:00 AM on that date. 4. Interviews with staff 1 and staff 3 revealed that the medication error was not documented on the March 2024 MAR nor in any notes supplemental to the MAR.
Plan of Correction:	RMA?s will be in-serviced on proper documentation and reporting to ED and Healthcare Director. Staff will be in-serviced on proper policy and procedures as it pertains to this incident.