Hermitage Deep Run

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: 02/03/2025 arrival time 11:00am departure time: 4:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Inspector reviewed 4 resident records and 3 staff records. Observed a medication administration pass along with the pharmacy review and medication management plan. Reviewed health care oversight, infection control policy, six month practice plan of resident emergencies, fire and health inspection and review of emergency preparedness and response. Observed dietitian review and liability insurance. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/03/2026 arrival time: 11:00am departure time: 4:00pm 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 12/17/2026 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS, 22VAC40-73-(8) BUILDINGS AND GROUND and 22VAC40-80-(G7) COMPLAINT INVESTIGATION. Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 Additional Comments/Discussion: Interviewed Executive Director and Vice President of Clinical Services. Reviewed facility’s policy on Hoyer Lift usage along with staff training on 2 person assist when using Hoyer Lifts. Reviewed monthly pest control invoices for November 2025, December 2025 and January 2026. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Shelby Haskins, Licensing Inspector at 804-305-4876 or by email at shelby.haskins@dss.virginia.gov

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/2025 arrival time 1:10pm departure time 2:10pm 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 10/17/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 63.2-(16) PROTECTION OF ADULTS AND REPORTING Number of residents present at the facility at the beginning of the inspection: 43 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector interviewed the Executive Director and reviewed the facility's internal investigation. The resident's diagnosis of Alzheimer's and Post Traumatic Stress Disorder disabled the resident to provide details. The resident later denied the incident occurred. The facility's investigation of the incident was unfounded. The resident involved in the incident passed away on 10/29/2025. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/04/2025 arrival time: 12:30pm departure time: 2:40pm 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 08/24/2025 regarding allegations in the area(s) of: 22VAC40-73-(4) STAFFING AND SUPERVISION, 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES and 22VAC40-73-(10) ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Number of residents present at the facility at the beginning of the inspection: 90 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector interviewed Administrator, reviewed resident’s record and reviewed staff training in reference to the incident. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/04/2025 arrival time: 12:30pm to 2:40pm 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 08/21/2025 regarding allegations in the area(s) of: 22VAC40-73-(4) STAFFING AND SUPERVISION, 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 63.2-(16) PROTECTION OF ADULTS AND REPORTING and 22VAC40-80-(G7) COMPLAINT INVESTIGATION. Number of residents present at the facility at the beginning of the inspection: 90 . Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of staff records reviewed: 4 Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector interviewed Executive Director, reviewed resident record, reviewed facility’s internal investigation along with involved staff’s written statements, reviewed facility’s policy on staff use/prohibition of photographic and audio devices, observed staff training administered by facility in reference to resident rights and handling residents with aggressive behaviors and Dementia. Inspector also spoke with resident, who is unable to recall the incident. Additional Comments/Discussion: The evidence gathered during the investigation supported some, but not all of the allegation; area(s) of non-compliance with standard(s) or law were: 22VAC40-73-110.1 Staff general qualifications: All staff shall: 1. Be considerate and respectful of the rights, dignity and sensitivities of persons who are aged or infirm or who have disabilities. A violation notice was issued; any violation(s) not related to the (complaint(s)/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 Shelby Haskins, Licensing Inspector at (804) 305-4876or by email at shelby.haskins@dss.virginia.gov.

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: 02/14/2025 Arrival time: 11:07am Departure time: 3:40pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Residents were observed participating in a Valentine’s Day Party arraigned by the facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.haskins@dss.virginia.gov.

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/26/2024 arrival time 10:00AM departure time 2:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.haskins@dss.virginia.gov. Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 12/6/2024

Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:08/14/2024 Arrival time: 11:00AM Departure time: 12:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector completed an Initial inspection for new ownership of the facility. Measurements were taken for requested capacity. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov