Inspection Reports for The Harmony Collection at Roanoke – Assisted Living
VA, 24017
Back to Facility Profile
Inspection Report
Monitoring
Census: 77
Deficiencies: 0
Oct 23, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 2025-10-16 regarding allegations in resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were noted in the report.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Oct 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-27 regarding allegations in the area of resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within 5 business days of receipt.
Complaint Details
Complaint related to resident care and related services; the evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
Sep 10, 2025
Visit Reason
The inspection was a monitoring visit conducted on September 10, 2025, following a self-reported incident regarding allegations in resident care and emergency preparedness.
Findings
The investigation did not support the self-report of non-compliance with standards or law. No deficiencies were explicitly noted in the report.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Sep 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-08-20 regarding allegations related to resident care and related services at the facility.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified concerning individualized service plans (ISP) not accurately reflecting residents' assessed needs and failure to update ISPs for changes in residents' conditions.
Complaint Details
Complaint investigation was conducted based on a complaint received on 2025-08-20 regarding resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based on the uniform assessment instrument (UAI), admission physical examination, resident interview, fall risk rating, psychological, behavioral, and emotional assessments, and other sources. |
| Facility failed to ensure that individualized service plans were reviewed and updated as needed for a change of a resident's condition. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Dates of wound care notes: Wound care notes from 2025-01-08 to 2025-09-09 provided for resident 1
Number of dressing changes per week: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff 1 | Interviewed staff member who provided information about ISP and UAI accuracy and wound care services |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Sep 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-21 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
Complaint investigation related to resident care and related services; the complaint was not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Sep 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-25 regarding allegations in the area of personnel.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to personnel; the complaint was not substantiated.
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
Sep 10, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-08-18 regarding allegations in resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 1
Inspection Report
Monitoring
Census: 73
Deficiencies: 4
Sep 10, 2025
Visit Reason
The inspection was a monitoring visit conducted on September 10, 2025, following a self-reported incident received on August 18, 2025, regarding allegations in resident care and related services.
Findings
The investigation supported the self-report of non-compliance with multiple standards related to medication administration, hospice care coordination, and individualized service plan updates. Violations were issued for failure to complete the uniform assessment instrument correctly, lack of hospice plan of care documentation, failure to update the individualized service plan after a significant change, and medication administration errors involving residents.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. |
| Facility and licensed hospice organization failed to communicate and establish an agreed upon coordinated plan of care for a resident receiving hospice services. |
| Facility failed to ensure that the individualized service plan (ISP) was reviewed and updated as needed for a significant change of a resident's condition. |
| Facility failed to ensure that medications were administered in accordance with physician's or other prescriber's instructions, resulting in a medication error where resident 1 received medications belonging to resident 2. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 2
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Monitoring
Census: 73
Deficiencies: 2
Aug 12, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 08/12/2025 regarding allegations in resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to medication management, specifically failures in timely medication ordering and administration, and lack of communication with the prescribing physician about missed doses. Violations were issued based on these findings.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement portions of its medication management plan to ensure timely filling and refilling of prescription and over-the-counter medications and communication with prescribing physicians regarding medication administration issues. |
| Facility failed to ensure medications were administered according to physician's or prescriber's orders, resulting in missed doses of multiple medications for a resident. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Aug 11, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-08 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint related to resident care and related services; the allegations were not substantiated.
Report Facts
Number of resident records reviewed: 5
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Jul 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-12 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint #62450 regarding resident care and related services was investigated and found to be unsubstantiated.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Interviews conducted with residents: 0
Interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Jul 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-20 regarding allegations in the area of resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within 5 business days of receipt.
Complaint Details
Complaint #62520 regarding resident care and related services was investigated and found unsubstantiated.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 1
Resident interviews conducted: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Jul 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-04 regarding allegations in the area of resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within 5 business days of receipt.
Complaint Details
Complaint #62679 was investigated regarding resident care and related services; the allegations were not substantiated.
Report Facts
Number of residents present: 81
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Jul 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-04 regarding allegations related to resident care and related services at the facility.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. No deficiencies were cited during this complaint investigation.
Complaint Details
Complaint #62865 was received by VDSS Division of Licensing on 2025-06-04 regarding resident care and related services. The evidence gathered did not support the allegations of non-compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Conducted the complaint investigation and inspection visit. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Jul 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-02 regarding allegations in the areas of resident care and related services, and buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint #62966 was investigated with review of one resident record and one staff interview; the allegations were not substantiated.
Report Facts
Number of residents present: 81
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 5
Jul 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-02 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services and Buildings and Grounds. Multiple violations were cited including incomplete uniform assessment instruments, failure to update individualized service plans for hospice care and significant resident condition changes, unlocked medication storage, and unsanitary conditions in resident units.
Complaint Details
The complaint investigation was substantiated in part, with evidence supporting non-compliance in resident care and buildings and grounds. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that staff completing private pay Uniform Assessment Instruments (UAI) had proper training and approval signatures. |
| Facility failed to include hospice services in individualized service plans (ISP) for residents receiving hospice care. |
| Individualized service plans were not reviewed and updated for significant changes in resident condition. |
| Medication storage area (3rd floor medication cart) was left unlocked and unattended. |
| Furnishings, fixtures, and equipment including toilets, carpets, and resident units were not kept clean and in good repair, presenting health hazards. |
Report Facts
Number of residents present: 81
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews with residents: 2
Number of interviews with staff: 4
Inspection Report
Monitoring
Census: 83
Deficiencies: 0
Apr 10, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review compliance with admission, retention, discharge of residents, and resident care and related services regulations.
Findings
The inspection found no violations of applicable standards or laws during the visit. The inspector completed a tour of the physical plant and reviewed resident records without identifying any deficiencies.
Report Facts
Resident records reviewed: 9
Staff records reviewed: 0
Staff interviews conducted: 4
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 83
Deficiencies: 0
Apr 10, 2025
Visit Reason
An unannounced monitoring inspection was conducted to determine whether the provider had corrected or was in the process of correcting previously cited violations in the areas of resident care and related services.
Findings
The inspection yielded no violations of applicable laws or regulations.
Report Facts
Number of resident records reviewed: 16
Number of staff records reviewed: 11
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 88
Deficiencies: 0
Jan 23, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of personnel and resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were noted in the report.
Inspection Report
Monitoring
Census: 88
Deficiencies: 2
Jan 23, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2024-12-08 regarding allegations in resident care and related services.
Findings
The investigation confirmed non-compliance with medication administration standards, including a medication error where a resident did not receive their prescribed medication and it was given to another resident in error, and failure to document medication errors on the medication administration record (MAR).
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications are administered according to physician's or prescriber's instructions. |
| Facility failed to ensure that the medication administration record (MAR) included any medication errors or omissions. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Audit percentage: 10
Inspection Report
Monitoring
Census: 88
Deficiencies: 1
Jan 23, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 12/31/2024 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards or law, and violations were issued. The licensee has the opportunity to submit a plan of correction to address the cited violations and maintain future compliance.
Deficiencies (1)
| Description |
|---|
| Violation of standard 22VAC40-73-680-D related to resident care and related services. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Audit percentage: 10
Plan of correction submission timeframe: 5
Review request timeframe: 15
Public posting timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Renewal
Deficiencies: 16
Dec 3, 2024
Visit Reason
The inspection was a renewal inspection conducted to determine compliance with applicable standards and laws for the assisted living facility license renewal.
Findings
The inspection identified multiple areas of non-compliance including failures in staff orientation and training, incomplete resident personal/social data, missing signatures on individualized service plans (ISPs), medication management deficiencies, lack of timely health care oversight, incomplete resident rights reviews, and documentation issues related to medication administration and emergency orders.
Deficiencies (16)
| Description |
|---|
| Facility failed to ensure staff received required new orientation and initial training within first seven working days. |
| Direct care staff did not meet required annual training hours. |
| Facility failed to ensure tuberculosis risk assessment was completed prior to employment. |
| Fall risk rating was not reviewed and updated after resident falls. |
| Personal and social information was incomplete on admission records for residents. |
| Individualized service plans (ISPs) were not signed and dated by residents or legal representatives. |
| ISPs were not updated to reflect significant changes in resident condition such as diet changes. |
| Health care oversight by licensed health care professional was not conducted at least every six months. |
| Resident rights and responsibilities were not reviewed annually with residents and staff. |
| Medication management plan was not fully implemented, including failure to date opened medications and remove expired items. |
| Residents were permitted to keep medications in their rooms without capability for self-administration or physician orders. |
| Medication administration records (MARs) were incomplete, missing date/time and initials for administered medications. |
| Medications ordered for PRN administration were not available or properly stored at the facility. |
| Facility failed to document actions taken in response to medication review recommendations. |
| Do Not Resuscitate (DNR) orders were not accurately reflected in individualized service plans (ISPs). |
| Sworn disclosure statements or affirmations were not completed for all applicants for employment. |
Report Facts
Annual training hours for staff 1: 16.25
Annual training hours for staff 2: 16.75
Dates of resident 3 falls: 07/03/2024, 08/11/2024, 08/15/2024, 10/15/2024, 10/17/2024, 11/20/2024
Medication expiration date: 28
Date of hire for staff 3: 10/08/2024
Date of hire for staff 1: 11/15/2021
Date of hire for staff 2: 09/16/2023
Date of inspection: 12/03/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Conducted the inspection |
| Staff 1 | Non-licensed direct care staff with insufficient training hours | |
| Staff 2 | Non-licensed direct care staff with insufficient training hours and medication administration issues | |
| Staff 3 | Staff with missing orientation, training, and TB risk assessment documentation | |
| Staff 4 | Licensed Health Care Professional | Employed full-time, responsible for health care oversight and interviewed regarding multiple findings |
| Staff 5 | Interviewed regarding resident rights review and other findings | |
| Staff 6 | Interviewed regarding fall risk rating and health care oversight | |
| Staff 7 | Interviewed regarding orientation, training, and sworn disclosure statement | |
| Staff 8 | Documented medication administration for resident 4 | |
| Staff 10 | Missing sworn disclosure statement | |
| Director of HR | Director of Human Resources | Responsible for staff orientation and training compliance |
| HR Director | Human Resources Director | Responsible for tracking training hours and resident rights review |
| HCD | Health Care Director | Responsible for medication management and health care oversight |
| ED | Executive Director | Responsible for admission documentation and resident rights review |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Oct 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-03 regarding allegations related to Staffing and Supervision and Resident Care and Related Services.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. No deficiencies were cited as a result of this complaint investigation.
Complaint Details
A complaint was received by VDSS Division of Licensing on 09/03/2024 regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services. The evidence gathered during the investigation did not support the allegations.
Report Facts
Number of residents present: 93
Number of staff records reviewed: 20
Number of staff interviews conducted: 2
Number of resident records reviewed: 0
Number of resident interviews conducted: 0
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Oct 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-09-04 regarding allegations in the area of personnel.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to personnel issues; the allegations were not substantiated.
Report Facts
Number of residents present: 93
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of resident records reviewed: 0
Inspection duration hours: 5.25
Inspection Report
Monitoring
Census: 93
Deficiencies: 0
Oct 3, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 09/09/2024 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 93
Deficiencies: 2
Oct 3, 2024
Visit Reason
The inspection was a monitoring visit conducted on October 3, 2024, following a self-reported incident received on August 22, 2024, regarding allegations in resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards related to medication administration and documentation. Violations were issued for failure to administer medications according to physician orders and failure to document medication errors or omissions in the medication administration record (MAR).
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that medications are administered according to physician's or other prescriber's orders, including missed doses of SYNTHROID and failure to administer CLONIDINE as ordered based on blood pressure readings. |
| Facility failed to ensure that the medication administration record (MAR) includes documentation of any medication errors or omissions. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews conducted with staff: 2
Medication administration audit percentage: 10
Expected compliance rate: 95
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Oct 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-26 regarding allegations related to personnel, resident care and related services, and buildings and grounds at the facility.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection, including deficiencies in individualized service plans, documentation of rehabilitative services, medication storage and administration, and hazardous materials storage.
Complaint Details
Complaint investigation #60328 was conducted based on allegations received on 2024-07-26 concerning personnel, resident care, and buildings and grounds. The evidence gathered did not support the allegations of non-compliance.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) included all required components such as service provider, timing, expected outcomes, and code status. |
| Facility failed to ensure that services provided, evaluations of progress, and other pertinent information regarding rehabilitative services were recorded in the resident's record. |
| Facility failed to ensure that a resident capable of self-administering medication was permitted to keep medication in an out-of-sight place; medications were found unsecured in a resident's room who was not capable of self-administration and without signed orders. |
| Facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 2
Number of staff interviews conducted: 3
Number of resident interviews conducted: 2
Dates of wound care progress notes: 12
Compliance audit target: 10
Expected compliance rate: 95
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Oct 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-27 regarding allegations related to resident care and related services at the facility.
Findings
The investigation supported the allegation that the facility failed to ensure medications were administered according to physician or prescriber instructions, specifically regarding the administration of Enoxaparin Sodium Injection for one resident.
Complaint Details
The complaint was substantiated based on evidence including record review and staff interviews confirming non-compliance with medication administration standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, specifically the Enoxaparin Sodium Injection was not administered as ordered from 08/22 to 08/25. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Plan of correction audit percentage: 10
Expected compliance rate: 95
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Oct 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-14 regarding allegations in the area of resident care and related services at The Harmony Collection at Roanoke Assisted Living.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, two violations unrelated to the complaint were identified: failure to ensure individualized service plans included all required components, and failure to have a Do Not Resuscitate (DNR) order signed by the resident's attending physician.
Complaint Details
A complaint was received by VDSS Division of Licensing on 2024-09-14 regarding allegations in the area of resident care and related services. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that the comprehensive individualized service plan (ISP) included all required components, specifically regarding the description of identified needs, services to be provided, providers, timing, expected outcomes, and time frames. |
| The facility failed to ensure that a Do Not Resuscitate (DNR) Order is signed by the resident's attending physician. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 5
Jul 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-18 regarding allegations related to resident care and related services at the assisted living facility.
Findings
The investigation supported the allegations of non-compliance with multiple standards related to resident care, communication, fall risk assessments, uniform assessment instrument completion, individualized service plans, and medical treatment documentation. Violations were issued and plans of correction were required.
Complaint Details
The complaint investigation was substantiated with violations issued related to resident care and related services, including failure to update service plans, fall risk ratings, and medical treatment documentation.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure communication to keep direct care staff informed of significant happenings or problems experienced by residents was documented in resident records. |
| Facility failed to ensure fall risk rating was reviewed and updated at least annually, when resident condition changes, and after a fall. |
| Facility failed to ensure the uniform assessment instrument (UAI) was completed prior to admission, at least annually, and with significant resident condition changes. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for significant resident condition changes. |
| Facility failed to ensure medical procedures or treatments ordered by a physician were provided according to instructions and documented. |
Report Facts
Number of residents present: 91
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Number of resident interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Jul 2, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-06-28 regarding allegations related to resident care and related services at the assisted living facility.
Findings
The investigation supported the allegations of non-compliance with medication administration standards, specifically that a staff member failed to administer a resident's anti-seizure medication as prescribed and falsified medication administration records. Violations were issued and corrective actions were taken including removal of the staff member and implementation of medication audits.
Complaint Details
The complaint was substantiated. Evidence showed that a resident was transported to the emergency department due to medication omission leading to seizure activity. Staff 1 failed to administer Lacosamide 150 MG as prescribed and falsified the MAR documentation. Staff 1 was removed from employment and reported to the Board of Nursing.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications are administered in accordance with physician's or prescriber's instructions. |
| Medication administration record (MAR) did not contain all required components, including medication errors or omissions. |
Report Facts
Number of residents present: 90
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 1
Medication dose: 150
Date of missed medication dose: Jun 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Named in medication error finding; removed from employment and reported to the Board of Nursing | |
| Holly Copeland | Licensing Inspector | Conducted the inspection and is contact for questions |
Inspection Report
Monitoring
Census: 90
Deficiencies: 3
Jul 2, 2024
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2024-06-28 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to medication administration errors, including omission of medications for a resident. Violations were issued for failure to administer medications as ordered, incomplete medication administration records, and failure to properly document and notify regarding medication errors.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications are administered in accordance with physician's orders, resulting in a medication omission on 06/25/2024. |
| Facility failed to ensure the medication administration record (MAR) contained all required components, including medication errors or omissions. |
| Facility failed to ensure proper action, notification, and documentation following a medication error or adverse drug reaction. |
Report Facts
Residents present: 90
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 1
Medication omission date: Jun 25, 2024
In-service date: Jun 28, 2024
Medication refresher course date: Jul 9, 2024
MAR audit percentage: 10
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Jun 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-05-20 regarding allegations related to personnel at the facility.
Findings
The investigation confirmed non-compliance with licensing requirements as the facility administrator was found to be working with an expired assisted living facility administrator license. The facility separated employment with the unlicensed administrator and appointed a licensed administrator.
Complaint Details
The complaint was substantiated. The allegation was that the administrator was working under an expired license, which was confirmed by license lookup and staff interviews.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the administrator was licensed as an assisted living facility administrator or nursing home administrator as required by Virginia law. |
Report Facts
Number of residents present: 90
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 90
Deficiencies: 0
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 11, 2024, following a self-reported incident received on April 22, 2024, regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found during the inspection.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 90
Deficiencies: 2
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 11, 2024, following a self-reported incident received on May 14, 2024, regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards related to medication administration and medical treatment orders. Violations were issued for failure to administer medications and treatments according to physician or prescriber orders.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that medications are administered according to physician or other prescriber’s orders, resulting in missed doses of multiple medications for resident 1 due to pharmacy error and failure to send medication. |
| Facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to instructions and documented, including missed doses of Budesonide inhalation for resident 1. |
Report Facts
Number of residents present: 90
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Missed medication days: 4
Medication audit percentage: 10
Inspection Report
Monitoring
Census: 90
Deficiencies: 2
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2024-05-28 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards related to medication administration errors and documentation omissions. Violations were issued for failure to administer medications according to physician orders and for incomplete medication administration records.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician's or prescriber's orders, specifically a missed dose of Lacosamide on 05/25/2024. |
| Facility failed to ensure the medication administration record contained all required information, specifically documentation of medication errors or omissions. |
Report Facts
Residents present: 90
Resident records reviewed: 1
Staff records reviewed: 0
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Named in medication error finding; removed from employment and reported to Board of Nursing | |
| Staff 1 | Provided reports and interviews related to medication error | |
| Holly Copeland | Licensing Inspector | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Apr 16, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-03-20 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint investigation related to resident care and related services; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Apr 16, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-20 regarding allegations related to resident care and related services and staffing and supervision.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of resident care and related services, specifically related to failure to implement parts of the medication management plan regarding controlled substance counts at shift changes.
Complaint Details
Complaint related to allegations in resident care and related services and staffing and supervision. The evidence supported some of the allegations. A violation notice was issued related to medication management deficiencies.
Deficiencies (1)
| Description |
|---|
| Facility failed to implement a portion of its medication management plan, specifically regarding the methods to ensure accurate counts of controlled substances whenever assigned medication staff changes. |
Report Facts
Number of residents present: 93
Number of staff interviews: 2
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Apr 16, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-04-15 regarding allegations in the area of resident care and related services at The Harmony Collection at Roanoke Assisted Living.
Findings
The investigation supported the allegations of non-compliance with several standards related to mandated reporting of abuse, individualized service plans, medication management, and medication administration according to physician orders. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting non-compliance with standards related to resident care and medication administration.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that staff who are mandated reporters reported suspected abuse, neglect, or exploitation of residents as required by law. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least annually or as needed for significant changes. |
| Facility failed to implement medication management plan to ensure medications are filled and refilled timely to avoid missed doses. |
| Facility failed to ensure medications were administered according to physician's orders, including a resident being given two patches simultaneously contrary to orders. |
Report Facts
Residents present: 93
Resident records reviewed: 1
Staff interviews conducted: 3
Resident interviews conducted: 1
Missed medication doses: 4
Inspection Report
Monitoring
Census: 93
Deficiencies: 2
Apr 16, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-report received by VDSS Division of Licensing regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance with medication management standards, specifically regarding timely ordering and administration of medications, resulting in missed doses. Violations were issued related to failure to implement the medication management plan and failure to administer medications according to physician instructions.
Deficiencies (2)
| Description |
|---|
| Failure to implement portions of the medication management plan to ensure timely filling and refilling of prescription medications to avoid missed dosages. |
| Failure to ensure medications were administered in accordance with physicians' or prescribers' instructions. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Missing narcotic count: 29
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Mar 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-08 regarding allegations related to resident care and related services and staffing and supervision at The Harmony Collection at Roanoke Assisted Living.
Findings
The investigation supported some but not all allegations; non-compliance was found in resident care and related services. Violations included failure to report a major incident within 24 hours, failure to update individualized service plans annually, failure to administer medications according to physician orders, and failure to document medication errors in the medication administration record.
Complaint Details
The complaint was substantiated in part; the investigation supported some allegations related to resident care and related services but not all. The complaint involved issues with resident care and staffing and supervision.
Deficiencies (4)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure that the individualized service plan (ISP) was updated at least annually. |
| Facility failed to ensure that medications were administered according to physician's orders. |
| Facility failed to ensure that the medication administration record (MAR) included any medication errors or omissions. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Date of medication error: Mar 5, 2024
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 3
Mar 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-08 regarding allegations related to resident care and related services at the facility.
Findings
The investigation supported the allegations of non-compliance with several standards, resulting in violations related to failure to report major incidents timely, failure to provide services as specified in individualized service plans, and failure to administer medications according to physician orders.
Complaint Details
The complaint investigation was substantiated with violations issued. The complaint involved missed doses of seizure medication (LACOSAMIDE 150 MG) for resident 1 from 03/03/2024 to 03/08/2024, resulting in seizure activity and hospitalization. The facility failed to notify the licensing inspector of the incident and failed to notify the resident's responsible party about missed medication doses prior to the seizure event.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| Facility failed to ensure that services specified in the individualized service plan (ISP) were provided to the resident. |
| Facility failed to ensure that medications were administered in accordance with the physician's or prescriber's instructions. |
Report Facts
Residents present: 93
Resident records reviewed: 1
Staff interviews conducted: 3
Missed medication days: 6
Plan of correction training dates: Staff Reportable training scheduled for 04/25 & 04/26; Managers provided Reportable Grid on 04/19/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Conducted the inspection and investigation |
Inspection Report
Renewal
Deficiencies: 3
Feb 6, 2024
Visit Reason
The inspection was conducted as a renewal inspection of The Harmony Collection at Roanoke Assisted Living to assess compliance with applicable standards and laws.
Findings
The inspection identified multiple violations including failure to ensure direct care staff received first aid certification within 60 days of employment, failure to update individualized service plans to reflect current physical therapy services, and failure to administer medications according to physician orders.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment. |
| Facility failed to ensure that the individualized service plan contained a description of identified needs based on services being received. |
| Facility failed to ensure that medications were administered in accordance with physician's or other prescriber's instructions. |
Report Facts
Inspection days: 2
Blood pressure readings above threshold: 7
Medication administration errors: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Conducted the inspection and can be contacted for more information |
| Staff 3 | Direct care staff member lacking first aid certification | |
| Staff 6 | Interviewed regarding first aid certification and medication administration | |
| Staff 1 | Provided information about medication cart and storage |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Sep 7, 2023
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2023-09-05 regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. Violations related to medication management were identified, including failure to properly document administration of controlled substances and medication administration records.
Complaint Details
The complaint was substantiated in part, with evidence supporting non-compliance in Resident Care and Related Services. A violation notice was issued, and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement a portion of its medication management plan regarding monitoring medication administration and accurate counts of controlled substances. |
| Facility failed to ensure that the medication administration record (MAR) included the date, time given, and initials of direct care staff administering medication. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 1
Number of resident interviews: 2
Number of staff interviews: 3
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Jul 11, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-06-27 regarding allegations related to resident care, laundry services, and the monthly menu.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection included a tour of the physical plant and review of resident records.
Complaint Details
Complaint #57641 was investigated; the evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 94
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Deficiencies: 16
Feb 7, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to staff records, resident records, medication administration, physical plant maintenance, and documentation requirements. The facility was cited for non-compliance in areas including staff certification, resident assessments, medication orders and administration, oxygen therapy orders, and physical plant safety.
Deficiencies (16)
| Description |
|---|
| Failed to ensure documentation of certain personal and social data is maintained on staff records, including verification of medication aide registration and job description receipt. |
| Failed to ensure each direct care staff member has current certification in adult first aid. |
| Failed to ensure physical examination report for a resident within 30 days preceding admission contained all required components. |
| Failed to ensure annual tuberculosis risk assessment was completed for each resident. |
| Failed to ascertain and document prior to admission whether a potential resident is a registered sex offender. |
| Failed to ensure private pay uniform assessment instruments were completed as required. |
| Failed to include hospice care services on individualized service plan when hospice care is provided. |
| Failed to ensure individualized service plan was signed and dated by resident or legal representative. |
| Failed to retain signed written or dated oral physician orders in resident records. |
| Failed to administer medications within one hour before or after the facility's standard dosing schedule. |
| Failed to administer medications in accordance with physician instructions, including holding medication based on blood pressure parameters. |
| Failed to include all required components in physician's oxygen therapy orders. |
| Failed to include a written Do Not Resuscitate (DNR) order in the individualized service plan. |
| Failed to ensure cleaning supplies were stored in a locked area. |
| Failed to maintain the interior of the building in good repair, including a soft or spongy area in hallway flooring. |
| Failed to obtain criminal history record check on or prior to the 30th day of employment for each employee. |
Report Facts
Inspection duration: 8
Resident admission date: Jan 7, 2023
Resident admission date: Oct 31, 2022
Staff hire date: May 24, 2022
Staff hire date: Oct 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Named as the current inspector conducting the inspection |
| Staff 2 | Named in findings related to medication aide certification, medication administration timing, and record documentation | |
| Staff 3 | Named in finding related to delayed criminal history record check | |
| Staff 5 | Named in findings related to medication aide registration documentation | |
| Staff 6 | Named in finding related to delayed criminal history record check | |
| Staff 7 | Named in findings related to staff certification and physical plant observations | |
| Staff 8 | Named in findings related to resident sex offender checks and medication orders |
Inspection Report
Monitoring
Census: 74
Deficiencies: 0
Jul 8, 2022
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident accommodations and related provisions.
Findings
The inspection found no violations of applicable standards or laws during the tour of the physical plant and review of resident records and staff interviews.
Report Facts
Number of resident records reviewed: 2
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 67
Deficiencies: 4
May 10, 2022
Visit Reason
The inspection was a monitoring visit conducted on May 10, 2022, following a self-reported incident received by VDSS Division of Licensing on February 11, 2022, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. The facility failed to report an incident threatening resident health within 24 hours, failed to obtain timely physician-signed orders, failed to administer medication as prescribed, and failed to correctly document medication administration records.
Deficiencies (4)
| Description |
|---|
| Facility failed to report an incident that threatens the health of a resident within 24 hours. |
| Facility failed to obtain an order signed by a physician within 14 days of an oral order to discontinue a medication. |
| Facility failed to administer a medication in accordance with a prescriber's order. |
| Facility failed to correctly document a medication record (MAR). |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
May 10, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-04-07 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The licensing inspector conducted a tour, reviewed records, and interviewed residents and staff, finding no substantiated deficiencies.
Complaint Details
Complaint related to Resident Care and Related Services; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 5
Number of resident interviews: 10
Number of staff interviews: 3
Inspection Report
Annual Inspection
Deficiencies: 8
Jan 6, 2022
Visit Reason
Two inspectors conducted an on-site annual monitoring inspection including review of resident and staff records, observation of a medication pass, and a physical plant tour.
Findings
Multiple deficiencies were found related to staff training, resident record documentation, uniform assessment instruments, and individualized service plans, with corrective actions planned or completed for each.
Deficiencies (8)
| Description |
|---|
| Facility failed to provide required staff training concerning residents with serious cognitive impairments within four months of starting employment. |
| Facility failed to retain written acknowledgment of the receipt of the disclosure by the resident or legal representative in the resident's record. |
| Facility failed to ensure that direct care staff had at least 18 hours of annual training. |
| Facility failed to document in a resident record that a sex offender screening had been done. |
| Facility failed to complete uniform assessment instruments (UAI) correctly, showing conflicting information in resident assessments. |
| Facility failed to show a service on an individualized service plan (ISP). |
| Facility failed to obtain required signature(s) on an individualized service plan (ISP). |
| Facility failed to update a resident's individualized service plan with current dates of expected outcomes. |
Report Facts
Resident records reviewed: 9
Staff records reviewed: 3
Inspection duration hours: 6.75
Staff training hours required: 18
Staff training hours completed: 14
Inspection Report
Renewal
Census: 44
Deficiencies: 1
Jan 28, 2021
Visit Reason
A renewal inspection was initiated on January 28, 2021 and concluded on February 4, 2021 to assess compliance with applicable standards and regulations.
Findings
The inspection found non-compliance related to an incomplete physician order for oxygen for a resident, specifically lacking information about the delivery device. A plan of correction was submitted to address this deficiency.
Deficiencies (1)
| Description |
|---|
| The facility failed to have a complete order for oxygen for a resident, missing information regarding the delivery device. |
Report Facts
Census: 44
Loading inspection reports...
