Virginia DSS · Assisted Living Facility

Hermitage Roanoke

📍 1009 Old Country Club Road, N.W., Roanoke, VA, 24017

ID 8605Two Year licenseActive
14
Inspections
On record
13
With violations
Visits that cited something
1
Clean visits
Nothing cited
43
Violations cited
Individual findings
32
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Hermitage Roanoke was inspected 14 times between October 20, 2020 and February 18, 2026 by the Virginia Department of Social Services. 13 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 43 violations under 32 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 10 of these 14 are still on the state's site; the other 4 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
04/14/2027
Administrator
Michael Davis
Licensing inspector
Angela Swink
Inspector phone
(276) 623-6575
Approved for
Assisted Living · Non-Ambulatory

Inspection History

14

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

February 18, 2026Inspection2 violations
Inspection dates
02/18/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
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: 02/18/2026 08:40 t0 14:00 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medication Cart Audit, Medication Pass Observation, Lunch Meal 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 Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on physical plant observation and staff interview, the facility failed to ensure that the facility shall store cleaning supplies and other hazardous materials in a locked area, except as noted in subsection J of this section.
Evidence
  1. The Licensing Inspector observed a spray can of Citrex Hospital Spray Disinfect and a spray bottle with a handwritten label Spray N Go Disinfectant Cleaner located in the unlocked, opened door of the staff lounge on Floor 2 in the unlocked cabinet underneath the sink, both with contents in their containers. Staff 1 and Staff 2 observed the two cleaners as they were present during the physical plant tour.
Plan of correction
1. The identified disinfectant was immediately removed and secured in a locked storage area on February 18, 2026. The cabinet was verified to ensure compliance with proper locking procedures. 2. An audit will be conducted of all cabinets, break rooms, medication rooms, housekeeping closets, and storage areas to ensure: • All cleaning supplies and hazardous materials are stored in locked areas • Cabinets and storage areas are properly secured Any identified concerns will be corrected immediately. Audit will be completed by 02/20/2026. 3. Education will be provided to all nursing staff and relevant personnel regarding the importance of proper storage of cleaning supplies and hazardous materials, compliance with 22VAC40-73-860(I), facility policy, and expectations for immediate corrective action if supplies are found unsecured. Education will be completed by 03/04/2026. 4. The Administrator/Designee will conduct weekly audits of all storage areas for six consecutive weeks beginning 02/25/2026 to ensure continued compliance. Documentation of audits and corrective actions (if needed) will be maintained. Results will be reviewed in the quarterly QA meeting.
22VAC40-73-1040-A
Based on physical plant observation, the facility failed to ensure that doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Residents with serious cognitive impairments may be limited but not prohibited from exiting the facility or any part thereof. Before limiting any resident from freely leaving the facility, the resident's record shall reflect the behavioral observations or other bases for determining that the resident has a serious cognitive impairment and cannot recognize danger or protect his own safety and welfare.
Evidence
  1. Interview with Staff 3 confirmed the facility currently serves a mixed population. 2.The Licensing Inspector (LI) observed the door leading to the outside in the sunroom and the door leading to the outside at the other end of the hallway of the same sunroom, with the stop sign on the door, on the ground floor, being able to be opened. The LI observed a white mechanism on the door and the door frame.
  2. Interview with Staff 1 confirmed the facility had a Situational Awareness and Response Assistant (SARA), that when these two doors were opened an alarm was to be sent to the direct care staff facility cell phone and each computer at the nurses stations. There were not any direct care staff that responded to the doors being opened during the time the LI and Staff 1 and Staff 2 were present in this area of the facility.
  3. The Licensing Inspector observed that the computers at the nurse station on the ground floor and first floor did not have an alarm sounding. The computer at the nurse station on the ground floor was not connected to the system and the computer on the first floor nurse station had the volume muted so the alarm could not be heard. Staff 1 and Staff 2 were present during these observations.
  4. Interview with Staff 4 confirmed that the direct care staff facility cell phone did not receive notifications of the door alarms.
  5. Interview with Staff 1 confirmed that the direct care staff facility cell phone was new and that it had not been updated to receive SARA notifications.
Plan of correction
1. The door alarm system was assessed immediately following identification of the concern. A technician serviced and corrected the phone alert system on 02/25/2026 to ensure notifications properly transmit to staff phones. The computer alert volume was restored to ensure audible notification. 2. An audit will be conducted of all exterior doors and alarm notification systems to ensure: • Door alarms activate properly • Notifications transmit to staff phones • Computer volume settings are operational Any identified concerns will be corrected immediately. Audit will be completed by 02/20/2026. 3. Education will be provided to all nursing staff and relevant personnel regarding the importance of door alarm monitoring, ensuring staff phones are operational and accessible, maintaining computer alert volume, and expectations for immediate response to alarm activation. Education will be completed by 03/04/2026. 4. The Administrator/Designee will conduct weekly audits of all exterior doors and alarm notification systems for six consecutive weeks beginning 02/25/2026 to ensure continued compliance. Documentation of alarm testing and corrective action (if needed) will be maintained. Results will be reviewed in the quarterly QA meeting.
September 11, 2025Inspection3 violations
Inspection dates
09/11/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
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: 9/11/2025 09:30 to 13:00 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 regarding allegations in the area(s) of: Resident Care and Related Services, Personnel and Mixed Population Number of resident records reviewed: 1 Number of staff records reviewed: 10 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services, Mixed Population A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that Individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident 1 record contained Progress Notes, with documentation that the resident was having recent behaviors of fecal smearing during the night on 8/27/2025, the resident was observed destroying their brief, rejection of care, and screaming when touched on 8/22/2025, having bowel movements in bowls in their room on 8/20/2025, fecal smearing at night on 8/14/2025, reports of fecal smearing on 8/8/2025, being agitated with staff unable to redirect on 8/6/2025, reaching into the toilet, grabbing BM, and wiping on the floor and/or walls, coming out in the hallways with pants around ankles and confused on 8/6/2025. 2.Resident 1 record contained an ISP, dated 4/25/2025, with documentation that the resident has appropriate behavior. 3.Interview with Staff 2 confirmed that the resident had an identified need with their behavior however the ISP had not been updated to reflect this significant change in a resident’s condition.
Plan of correction
Corrective Action Taken: o Resident 1’s ISP was immediately updated on 9/11/2025 to reflect current behavioral needs. Audit: o A facility-wide audit of all ISPs will be completed by 9/22/2025 to ensure that all resident plans reflect current conditions, including behavioral, medical, and functional changes. Plan to Prevent Recurrence: o Staff qualified to develop ISPs will receive education on requirements for timely updates following significant changes. Compliance & Monitoring: o Beginning 9/23/2025, compliance checks will occur weekly for three months (through 12/23/2025) to verify ISP accuracy and timeliness. o Documentation of checks will be reviewed by the DON or designee and corrective action taken as needed.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. Resident 1 record contained Progress Notes, with documentation that the resident was having recent behaviors of fecal smearing during the night on 8/27/2025, the resident was observed destroying their brief, rejection of care, and screaming when touched on 8/22/2025, having bowel movements in bowls in their room on 8/20/2025, fecal smearing at night on 8/14/2025, reports of fecal smearing on 8/8/2025, being agitated with staff unable to redirect on 8/6/2025, reaching into the toilet, grabbing BM, and wiping on the floor and/or walls, coming out in the hallways with pants around ankles and confused on 8/6/2025.
  2. Resident 1 record contained a Uniform Assessment Instrument, dated 4/25/2025, with documentation that the resident’s behavior pattern was appropriate.
  3. Interview with Staff 2 confirmed that Resident 1 had a significant change in condition and the UAI was not updated for this change.
Plan of correction
Corrective Action Taken: o Resident 1’s UAI was immediately updated on 9/11/2025 to reflect current behaviors and condition. Audit: o An audit of all residents displaying behaviors will be completed by 9/22/2025 to ensure UAIs are accurate and updated in accordance with state regulations. Any discrepancies identified will be corrected promptly. Plan to Prevent Recurrence: o Staff members trained and authorized to complete UAIs will receive re-education on the importance of timely updates when significant changes occur. o Documentation standards will be reinforced, with emphasis on accurately capturing behavioral changes. Compliance & Monitoring: o Weekly compliance checks of UAIs will be conducted for three months (through 12/11/2025) to ensure all significant changes are reflected. o DON or designee will review and additional training will be provided if deficiencies are identified.
22VAC40-73-1030-B
Based on staff record review and staff interview, the facility failed to ensure that within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment, and the training shall meet the requirements of subsection C of this section.
Evidence
  1. The facility has a mixed population.
  2. Staff 3 record, date of hire 11/24/2024, contained documentation for five hours of training in working with individuals who have a cognitive impairment. Staff 3 is direct care staff.
  3. Interview with Staff 2 and Staff 13 confirmed Staff 3 did not have the required six hours of training in working with individuals who have a cognitive impairment and worked with individuals with a cognitive impairment.
Plan of correction
Corrective Action Taken: o Staff 3 immediately completed the required hours of cognitive impairment training. Documentation is on file. Audit: o An audit of all direct care staff files conducted by 9/23/2025 to verify completion of required cognitive impairment training within the regulatory time frame. Any deficiencies will be corrected immediately. Plan to Prevent Recurrence: o A 12-month training plan has been developed to ensure all staff receive training that meets or exceeds state standards for cognitive impairment care. o Orientation processes have been revamped to ensure new hires complete necessary cognitive impairment training before beginning independent shifts. Compliance & Monitoring: o Starting 9/23/2025, weekly compliance checks will be performed for three months (through 12/23/2025) to ensure all training requirements are met. o Training records will be maintained in personnel files and reviewed by administration during ongoing quality assurance processes.
January 27, 2025Inspection1 violation
Inspection dates
01/27/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: 1/27/2025 08:45 to 15:00 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: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication Pass, Medication Cart Audit, Lunch Meal 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. 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on medication cart audit, resident record review, and staff interviews, the facility failed to ensure that medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. Resident 6 record contained a signed physicians’ order dated 12/16/2024 that contained documentation for Voltaren External Gel 1% (Diclofenac Sodium (Topical)) Apply to bilateral shoulders topically every 6 hours as needed for pain and a signed physician’s order dated 12/19/2024 that contained documentation for Tylenol Oral Tablet 325mg (Acetaminophen) Give 2 tablet by mouth every 24 hours as needed for pain. These two medications are ordered for PRN administration.
  2. During the medication cart audit with the licensing inspector and staff 4, staff 4 was unable to locate the Voltaren External Gel 1% and the Tylenol Oral Tablet 325mg on the medication cart, as well as the locked nurses station area.
  3. During an interview with the licensing inspector and staff 2, staff confirmed the facility did not have these medications ordered for PRN administration available and properly labeled for the specific resident.
Plan of correction
Not published by VDSS.
February 28, 2024Inspection5 violations
Inspection dates
02/28/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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: 2/28/2024 08:40am to 02:45pm 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: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 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. 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-990-C
Based on facility record review and staff interview, the facility failed to ensure, at least once every six months, staff participate in an exercise in which the procedures for resident emergencies are practiced.
Evidence
  1. During an on-site inspection on 2/28/2024, the facility record contained a drill for the plan for resident emergencies and practice exercise dated 6/30/2023.
  2. An interview conducted with one licensing inspector and staff person 2, staff person 2 revealed the facility record was current.
Plan of correction
Staff have participated in every 6-month drill and practice exercise for resident emergencies. Nursing leadership has been educated on ensuring staff participate in a drill and practice exercise for resident emergencies every 6 months. Director of Nursing, or designee, will establish a calendar for resident emergency drills and practice exercises. Executive Director, or designee, will review exercise report after completion of each 6-month drill and practice exercise for resident emergencies.
22VAC40-73-410-A
Based on resident record review and staff interview, the facility failed to provide an orientation for a new resident with acknowledgment of having received the orientation with documentation signed and dated by the resident or legal representative.
Evidence
  1. The record for resident 2, admitted on 2/2/2024, did not contain documentation of receiving orientation. 2.During the on-site inspection on 2/28/2024, an interview conducted with one Licensing Inspector and staff person 2, staff person 2 revealed record for resident 2 was current.
Plan of correction
Record for resident 2 is current. Sales team has been educated on ensuring orientation is provided upon admission and signed acknowledgment with documentation is obtained. Marketing Director, or designee, will audit resident files at or prior to admission to ensure orientation has been provided and signed acknowledgement is obtained. Executive Director, or designee, will conduct audits of new resident files to ensure continued compliance.
22VAC40-73-700-1
Based on resident record review and staff interview, the facility failed to ensure the physician’s order for oxygen for a resident contained the oxygen source and delivery device.
Evidence
  1. The record for resident 5 contained a signed physician’s order, dated 2/13/2024, ordering O2 @ 2L HS at bedtime. 2.During the on-site inspection on 2/28/2024, an interview conducted with one Licensing Inspector and staff person 1, staff person 1 revealed record for resident 5 was current.
Plan of correction
Record for resident 5 is current. Nursing staff have been educated on ensuring physician orders for oxygen include the source and delivery device. Director of Nursing, or designee, will audit all physician orders for oxygen to ensure oxygen source and delivery device are included. Executive Director, or designee, will conduct a monthly audit of oxygen order to ensure continued compliance.
22VAC40-73-450-D
Based on resident record review and staff interview, the facility failed to ensure the services provided by hospice care is included on the individualized service plan (ISP).
Evidence
  1. The record for resident 4 contained a signed physician’s order, dated 11/22/2023, ordering a consult for hospice for end of life. The ISP in the record, dated 10/10/2023, included hospice as a need (focus), however did not include the services provided by hospice. 2.During the on-site inspection on 2/28/2024, an interview conducted with one Licensing Inspector and staff person 1, staff person 1 revealed record for resident 4 was current.
Plan of correction
Record for resident 4 is current. Nursing leadership has been educated on ensuring services provided by hospice care are included on the individualized service plan (ISP). Director of Nursing, or designee, will audit hospice resident files to ensure hospice services are appropriately included on ISPs. Executive Director, or designee, will conduct a monthly audit of hospice resident files to ensure continued compliance.
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to ensure prior to admission whether a potential resident is a registered sex offender.
Evidence
  1. The record for resident 2, admission date 2/2/2024, contained a Virginia State Police Sex Offender search result dated 2/5/2024. 2.During the on-site inspection on 2/28/2024, an interview conducted with one Licensing Inspector and staff person 2, staff person 2 revealed the record for resident 2 was current.
Plan of correction
Record for resident 2 is current. Sales team has been educated on ensuring sex offender screening is completed prior to admission. Marketing Director, or designee, will audit resident files at or prior to admission to ensure checks are completed appropriately. Executive Director, or designee, will conduct audits of new resident files to ensure continued compliance.
January 30, 2023Inspection7 violations
Inspection dates
01/30/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/30/2023 8:30am until 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: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed:6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. The ISP for resident 1, dated 12/30/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative.
  2. The ISP for resident 2, dated 12/15/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative.
  3. The ISP for resident 3, revised on 01/03/2023, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative.
  4. The ISP for resident 6, revised 02/25/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative.
  5. The ISP for resident 9, revised on 04 13/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative.
Plan of correction
ISPs for Residents 1, 2, 3, 6, and 9 have been signed by the person who developed the plan and the resident or their legal representative. ISP trained team have been educated on ensuring all ISPs are signed by the person who developed the plan and the resident or their legal representative. Director of Nursing, or designee, will audit all resident files to ensure ISPs are signed by appropriate persons. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.
Evidence
  1. The second floor laundry was noted to be unlocked on the day of inspection. The lower cabinet to the right was observed to be unlocked and contained a bottle of Dispatch Hospital Cleaner/Disinfectant towels with Bleach, a bottle of Clorox Bleach Germicidal cleaner and a bottle of Envirox Carpet Sport and Stain Remover.
  2. The second floor nursing station was observed to be unlocked and unattended on the day of inspection. A bottle of Dispatch Hospital Cleaner/Disinfectant towels with Bleach was sitting out on the counter by the sink and a bottle of Hydrogen Peroxide was observed in the unlocked cabinet above the sink.
  3. The second floor pantry was observed unlocked on the day of inspection. A bottle of Champion Spray Disinfectant and a bottle of Pine-sol was observed in the unlocked lower cabinet under the microwave and sink.
Plan of correction
Cleaning supplies found in the second floor laundry, nurses’ station, and pantry have been appropriately stored in a locked area. Team members have been educated on ensuring all cleaning supplies are stored in a locked area. Director of Nursing, or designee, will perform daily rounds for one month to ensure cleaning supplies are stored appropriately in a locked area. Executive Director, or designee, will conduct weekly rounds for one month to ensure continued compliance.
22VAC40-73-650-C
Based on resident record review, the facility failed to ensure that orders were signed by a residents physician within 14 days.
Evidence
  1. The record for resident 5 has an electronic physician order dated 01/04/2023 for Vitamin D 50mcg by mouth daily. The order does not contain the signature of the resident physician as of the date of inspection.
Plan of correction
Resident 5’s order for Vitamin D 50mcg by mouth daily has been signed by the physician. Nursing leadership has been educated on ensuring all orders are appropriately signed by the residents’ physician. Director of Nursing, or designee, will audit all resident files to ensure orders are signed by appropriate physician. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. The record for resident 6 has a hospice assessment noted dated 01/20/2023 for the resident to receive oxygen 2liters/min via nasal cannula continuously. The ISP for resident 6 is inconsistent as it has the use of oxygen for 8 to 20 hours during the night. Interview with staff 4 expressed that the ISP is incorrect and that resident 6 is using oxygen continuously.
  2. The record for resident 9 has documentation of a physician order 07/20/2022 for a protective brace to left hand one time a day for severe thumb arthritis at CMC, MCP and JP joints. The ISP in the record for resident 9 does not address this identified need.
Plan of correction
Resident 6’s ISP has been updated to reflect continuous oxygen use. Resident 9’s order for a protective brace to left hand has been discontinued and the ISP reflects this change. ISP trained team have been educated on ensuring identified needs are addressed on each resident’s ISP. Director of Nursing, or designee, will audit all resident files to ensure ISPs are complete and accurate. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-640-A
Based on record review and observation, the facility failed to implement its medication management plan, specifically regarding methods to ensure that each resident’s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The facility’s Medication Management Plan (revised 5/2022) states the following: “Adequate supplies of medications will be maintained at the facility. A refill request will be sent to the pharmacy when a 5-day supply remains to allow for timely refill of the prescription. New resident’s orders will be entered electronically and pharmacy will be contacted to ensure orders received.”
  2. The record for resident 7 contained physician’s orders, signed 01/01/2023, which included Donepezil HCl Tablet 10 MG “Give 1 tablet by mouth at bedtime related to unspecified Dementia without behavioral disturbance”.
  3. Progress notes for resident 7 indicate that the facility was waiting for Donepezil HCl Tablet 10 MG to be delivered by the pharmacy on 01/01/2023, 01/02, 01/03, 01/04, 01/07, 01/08, 01/11, 01/16, 01/17, and 01/18/2023. The January 2023 MAR for resident 7 indicates that this medication was not administered on those dates.
Plan of correction
Clinical team members certified to administer medications are following the facility medication management plan as it relates to filling and refilling medications. Clinical team members certified to administer medications have been educated on the facility medication management plan and appropriate processes for filling and refilling medications. Director of Nursing, or designee, will conduct weekly audits of all medication carts for one month to ensure the medication management plan is being followed correctly. Executive Director, or designee, will audit one randomly selected medication cart monthly to ensure continued compliance.
22VAC40-73-660-A-1
Based on observations of the facility physical plant, the facility failed to ensure that medications prescribed to residents were stored in a locked area.
Evidence
  1. The second floor nursing station was observed to be unlocked and unattended at 9:24am on the day of inspection. Two bags labeled “Pharmacy Return” were observed sitting out on the cabinet beside the copy/fax machine. The bags contained numerous medications for multiple residents.
Plan of correction
All nurses’ stations are locked and appropriate team have keys for access. Clinical team members have been educated on ensuring all nurses’ station doors remain locked. Director of Nursing, or designee, will perform daily checks for one month to ensure nurses’ station doors are appropriately locked. Executive Director, or designee, will conduct weekly audits for one month to ensure all nurses’ station doors remain locked.
22VAC40-73-210-D
Based on record review, the facility failed to ensure that the annual training for medication aides shall include continuing education as required by the Virginia Board of Nursing.
Evidence
  1. The Virginia Board of Nursing’s Regulations Governing the Registration of Medication Aides, effective 02/06/2020, list that the continuing education required for registered medication aides shall consist of four hours of population-specific training in medication administration in the assisted living facility in which the aide is employed or a refresher course in medication administration offered by an approved program.
  2. The record for staff 5, hired 03/25/2019, did not contain documentation that this staff member had taken four hours of population-specific training in medication administration or an annual medication administration refresher course for 2020, 2021, or 2022.
  3. Interview with staff 4 could not verify that staff 5 had taken four hours of population-specific training in medication administration or an annual medication administration refresher course for 2020, 2021, or 2022.
Plan of correction
Staff 5 has been registered to attend an annual medication administration refresher course meeting VA Board of Nursing regulation. All Registered Medication Aides have received education on VA Board of Nursing’s annual training requirements. Director of Nursing, or designee, will audit all RMA employee files to ensure appropriate annual training has occurred. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected RMA employee files to ensure continued compliance.
May 11, 2022Complaint survey3 violations
Inspection dates
05/11/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/11/2022 9:30am until 3:00pm 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 04/14/2022 regarding allegations in the areas of: administration and administrative services, personnel, Staffing and supervision, admission, retention and discharge of residents, resident care and related services and building and grounds. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area of non-compliance with standard(s) or law were: resident care and related services. A violation notice was issued; 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-930-B
Based on observations made of the facility physical plant, the facility failed to ensure that a signaling device that terminates at a central location was continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. At 10:54am on the day of inspection both LI’s activated the signaling device located in room 305. The light above the door to room 305 was visibility lit, but the signaling device was not auditable in the hallway and did not ring to the designated location at the nurses desk.
Plan of correction
The audible station connected to the signaling device had become unplugged and was reconnected. Staff have been stationed at the monitoring devices to ensure all call signals were identified and resolved. A new signaling system has been installed to ensure appropriate functioning of the system which now alerts visibly and audibly on all floors as well as a terminating at a central location that is continuously staffed. Team members have been educated on notifying the maintenance department immediately if any issues with the new system are identified. Director of Environmental Services, or designee, will conduct daily audits of each resident hallway to ensure continued functioning of the signaling system. Executive Director, or designee, will conduct weekly audits of 3 apartments (1 on each floor) to ensure continued functioning.
22VAC40-73-680-D
Based on a review of resident records and medication administration records (MARs), the facility failed to administer medications in accordance with physician instructions.
Evidence
  1. The April and May 2022 MAR for resident 12 has documentation of a physician order dated 04/01/2022 to check the residents blood pressure twice a day, if systolic is greater than 180 or diastolic is greater than 100 give Hydralazine HCI 25mg every 6 hours as needed for HTN two times a day.
  2. The April and May 2022 MARs for resident 12 has documentation of the residents systolic blood pressure being over 180 or diastolic blood pressure being over 100 seven times from 04/06/2022 through 05/10/2022 but staff initials are not present for administering the Hydralazine 25mg for these blood pressure results.
Plan of correction
Resident 12’s Hydralazine HCI 25mg order has been updated to reflect appropriate systolic and diastolic ranges for BP checks twice per day and administration of medication if outside of range twice per day. Clinical team members are administering Resident 12’s Hydralazine HCI 25mg appropriately and initialing correctly on the MAR per the medication management plan. Clinical team members certified to administer medications have been educated on the facility medication management plan and processes. Director of Nursing, or designee, will conduct weekly audits of resident MARs to ensure the medication management plan is followed appropriately. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-450-F
Based on a review of resident records, observations of the facility physical plant and resident interview, the facility failed to ensure that individualized service plans (ISPs) were updated when a change in a resident occurred.
Evidence
  1. The record for resident 11 has documentation in progress notes dated 05/11/2022 that the resident has a diagnosis of “dementia in other diseases classified elsewhere with behavioral disturbance”. During an interview with resident 11 in her apartment on the day of inspection, it was noted that resident 11 had some confusion and kept asking where her mother and father were. It was observed by the LI that resident 11 had placed a chair and multiple boxes up against her door, blocking the door to her apartment to be opened effectively from the hallway. The ISP dated 02/20/2022 has that resident 11 does not have inappropriate behaviors at this time and has not been updated to reflect resident 11’s current behaviors.
Plan of correction
Resident 11’s ISP has been updated to reflect exhibited behaviors. ISP Trained staff have been educated on ensuring ISPs correctly reflect behavioral disturbances and any changes made to UAIs.Director of Nursing, or designee, will audit all resident files to ensure ISPs are complete and accurate. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
May 11, 2022Inspection1 violation
Inspection dates
05/11/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/11/2022 9:30am until 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a review of resident records, medication administration records (MARs) and facility documentation, the facility failed to ensure that medications administered to resident 1 were in accordance with physician orders.
Evidence
  1. A facility self-reported incident has documentation that on 05/03/2022 at 8:00am a Duragesic 25mcg/hr patch belonging to resident 2 was placed on resident 1.
  2. A review of the May 2022 MAR for resident 1 has documentation that the residents Fentanyl patch order is for 12mcg/hr transdermally every 72 hours. The May 2022 MAR for resident 2 has documentation that their Fentanyl patch order is for 25mcg/hr transdermally every 72 hours.
Plan of correction
Medications are being administered per physician’s instructions. Resident 1’s order for Duragesic patch was discontinued on 5/25/22. Clinical team members certified to administer medications have been educated on the facility medications management plan and appropriate processes. Director of Nursing, or designee, will conduct weekly audits of all medication carts to ensure medications are given per physician’s instructions. Executive Director, or designee, will audit all controlled substance count documents monthly to ensure continued compliance. Executive Director, or designee, will audit all medication carts monthly to ensure continued compliance.
May 11, 2022Inspection0 violations
Inspection dates
05/11/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/11/2022 9:30am until 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 3 Additional Comments/Discussion: Follow up inspection from previous violations. The facility medication carts were observed for proper glucometer labeling. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 7, 2022Inspection1 violation
Inspection dates
04/07/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
The LI for Hermitage Roanoke conducted an unannounced monitoring investigation on 04/07/2022 from a facility self reported incident. Facility documentation and resident medication administration records were reviewed. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations cited can be found on the violation notice. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.
Violations
22VAC40-73-680-D
Based on a review of facility documentation, medication administration records (MARs) and narcotic count logs, the facility failed to ensure that medications were administered in accordance with physician's instructions.
Evidence
  1. A facility incident report dated 04/02/2022 and updated 04/06/2022 has documentation that on 03/31/2022 at 8:20am a Duragesic patch prescribed for resident 1 was placed on resident 2. This was discovered by staff person 1 during the morning medication pass on 04/01/2022 and the incorrect patch was removed from resident 2.
  2. The March 2022 MAR for resident 1 has documentation that the residents Fentanyl patch order is for 25mcg/hr transdermally every 72 hours. The March 2022 MAR for resident 2 has documentation that their Fentanyl patch order is for 12mcg/hr transdermally every 72 hours.
Plan of correction
Medications are being administered per physician’s instructions. Clinical team members certified to administer medications have been educated on the facility medications management plan and appropriate processes. Agency staff will receive training as they are assigned to the community. Director of Nursing, or designee, will conduct weekly audits of all medication carts to ensure medications are given per physician’s instructions. Executive Director, or designee, will audit all controlled substance count documents monthly to ensure continued compliance. Executive Director, or designee, will audit all medication carts monthly to ensure continued compliance.
March 14, 2022Inspection9 violations
Inspection dates
03/14/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
To ensure the facility had a thorough understanding of standards, the LIs had a discussion with the Administrator, the Director of Nursing and the Assistant Director of Nursing regarding standards 310-D, 550-G and 700-2.
Comments
The licensing inspector (LI) for Hermitage Roanoke along with another LI, conducted an unannounced renewal study on 03/14/2022 from 8:40 AM until 4:50 PM, finding 49 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, a review of three medication storage carts, and resident interviews. Eight resident records were thoroughly reviewed, and an additional two were partially reviewed in relation to the observation of the medication pass. Sworn disclosure statements and criminal record checks were examined for all newly hired staff since the facility's last mandated inspection, and four staff records were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator, Director of Nursing and Assistant Director of Nursing on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. An additional phone call occurred with the Director of Nursing and the LI on 03/17/2022 to review the final violation notice. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-440-D
Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required.
Evidence
  1. The UAI for resident 2, dated 03/01/2022, showed the resident needs physical human help only with toileting. The individualized service plan (ISP), dated 03/01/2022, showed the resident needs physical human help and mechanical help with toileting. Interview with staff 6 and 7 indicated that the ISP is correct and the UAI is incorrect.
  2. The UAI for resident 8, dated 2/18/2022, indicated that the resident does not require any assistance with transferring and toileting; however, the individualized service plan (ISP) for resident 8, dated 2/18/2022, indicated that the resident requires mechanical help only. Interview with staff 5 indicated that the ISP for resident 8 is correct.
  3. The UAI for resident 8, dated 2/18/2022, indicated that the resident is continent of bladder; however, the ISP for resident 8, dated 2/18/2022, indicated that the resident is incontinent of bladder greater than weekly. Interview with staff 5 indicated that the ISP for resident 8 is correct.
Plan of correction
UAIs for resident 2 and resident 8 have been updated to accurately reflect identified needs on their respective ISPs. UAI trained staff have been educated on ensuring UAIs are accurately completed as changes are noted. Director of Nursing, or designee, will audit all resident files to ensure UAIs are complete and accurate. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continue compliance.
22VAC40-73-680-B
Based on observation during medication cart audits, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to residents.
Evidence
  1. The facility uses a pharmacy that packages each residents’ medications into individual white, square plastic bags that contain residents’ scheduled medications in single packs as well as PRN (as needed) medications.
  2. The first floor medication cart contained two bags, bag 1 of 4 and bag 2 of 4, that contained acetaminophen 325mg tablets (tabs). Bag 1 of 4 contained seven acetaminophen 325 mg tabs and bag 2 of 4 contained two acetaminophen 325 mg tabs. Both bags 1 and 2 did not contain the name of the resident(s) that these medications were for.
  3. The third drawer of the second floor medication cart contained three acetaminophen 325mg tabs and one vitamin D3 1,000U tab that were lying loose in individual packages in the bottom of the drawer and did not contain the name of the resident(s) that these medications were prescribed for.
Plan of correction
Medications without appropriate labeling have been removed from medication carts. Clinical team members certified to administer medications have been educated on how to appropriately tear open PRN medication packets, leaving resident and medication information intact, and what to do if labels are compromised. Director of Nursing, or designee, will conduct weekly audits of all medication carts to ensure medications are in appropriate containers with correct labels. Executive Director, or designee, will audit all medication carts monthly to ensure continued compliance.
22VAC40-73-100-C-2
Based on observation during medication cart audits, the facility failed to ensure that infection control policies that are consistent with CDC recommendations were followed.
Evidence
  1. The records for resident 11 and 12 contained physician’s orders (dated 03/13/2022 for resident 11 and 02/17/2022 for resident 12) for both residents to receive blood sugar checks.
  2. The first floor medication cart contained a glucometer for resident 11 and the third floor medication cart contained a glucometer for resident 12. Neither of the glucometers were labeled with the resident’s name per CDC recommendations.
Plan of correction
Glucometers for resident 11 and resident 12 have been labeled per CDC recommendations. Clinical team members certified to administer medications have been educated on appropriate labeling policies and CDC recommendations. Director of Nursing, or designee, will audit all medication carts to ensure glucometers are labeled appropriately. Executive Director, or designee, will conduct a monthly audit of all glucometers to ensure continued compliance.
22VAC40-73-660-B
Based on observation during medication cart audit, staff interview and resident record review, the facility failed to ensure that residents that had his own medication in their room the uniform assessment instrument (UAI) indicated the residents were capable of self-administering medication.
Evidence
  1. The UAI for resident 3, dated 04/14/2021, and resident 10, dated 02/25/2022, indicated that both resident 3 and 10 need their medications administered/monitored by lay person.
  2. The record for resident 3 contained a physician’s order, dated 03/06/2022, for nystatin-triamcinolone cream, 100000-0.1 apply to under right breast topically two times a day for yeast for 30 days. The licensing inspector (LI) was unable to locate this medication in the second floor medication cart and staff 4 indicated that the medication was located in resident 3’s room. Staff 4 obtained the medication from resident 3’s room and placed in back in the second floor medication cart. The order does not indicate that the resident can self-administer this medication.
  3. The record for resident 10 contained a physician’s order, dated 02/26/2022, for selsun blue dry scalp shampoo 1% apply to hair/skin topically every evening shift every Tue, Sat for dry itchy scalp/skin apply to hair/scalp on shower days tues/Sat. The LI was unable to locate this shampoo in the second floor medication cart and staff 4 indicated that the shampoo was located in resident 10’s room. LI observed this shampoo at approximately 11:32AM in the bathroom of resident 10’s room. The order does not indicate that the resident can self-administer this shampoo.
Plan of correction
The nystatin-triamcinolone cream for resident 3 and Selsun Blue for resident 10 were returned to the medication cart. Clinical team members have been educated on appropriate storage of ordered medications for residents requiring medication administration assistance. Director of Nursing, or designee, will audit apartments for all residents requiring medication administration assistance to ensure medications are not stored inappropriately. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected apartments of residents requiring medication administration assistance to ensure continued compliance.
22VAC40-73-680-G
Based on observation during medication cart audit, staff interview and resident record review, the facility failed to ensure over-the-counter medication was labeled with the resident’s name.
Evidence
  1. The record for resident 10 contained a physician’s order, dated 02/26/2022, for Eucerin lotion apply to face and ears topically in the morning for dry skin. The licensing inspector (LI) was unable to locate this lotion in the second floor medication cart. Staff 4 obtained a 16.9 ounce bottle of Eucerin intensive repair lotion from the sink in the staff lounge where the medication cart was located and indicated to the LI that it was resident 10’s lotion; however, it did not have the resident’s name on the bottle.
Plan of correction
Resident 10’s Eucerin lotion has been labeled and stored appropriately. Clinical team members certified to administer medications have been educated on appropriate labeling of over-the-counter medications. Director of Nursing, or designee, will conduct weekly audits of all medication carts to ensure over-the-counter medications are labeled and stored appropriately. Executive Director, or designee, will audit all medication carts monthly to ensure continued compliance.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) is completed as required.
Evidence
  1. The ISP for resident 7, dated 8/13/2021, indicated that the resident has wandering/passive behaviors greater than weekly; however, the uniform assessment instrument (UAI) for resident 7, dated 8/13/2021, indicated that the resident has wandering/passive behaviors less than weekly. Interview with staff 5 indicated that the UAI for resident 7 is correct.
  2. The ISP for resident 3, with a revision date of 03/04/2022, stated that the resident is receiving physical therapy, occupational therapy, and speech therapy and the ISP resident 4, with a revision date of 06/03/2021, stated that the resident is receiving physical therapy; however, neither ISP showed who or which entity is providing the therapy services.
Plan of correction
Resident 7’s ISP has been updated to accurately reflect the UAI. ISPs for resident 3 and resident 4 have been updated to reflect which entity is providing therapy services. ISP trained staff have been educated on appropriate process for ensuring ISPs are complete, accurate, and provide all necessary details. Director of Nursing, or designee, will audit all resident files to ensure ISPs are complete and accurate. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-640-A
Based on document review, the facility failed to implement their medication management plan.
Evidence
  1. The facility’s medication management plan, with a revision date of 03/2021, states on page 10 the following: “The Licensed Nurse/Registered Medication Aide ending their shift will count all controlled substances with the Licensed Nurse/Registered Medication Aide coming on duty. The controlled count is to be conducted where both persons can visualized [sic] the container of controlled substance and the controlled count sheet, so both can verify the accuracy of the count. Both must sign the count reconciliation sheet before leaving the medication cart.”
  2. At approximately 9:30AM during on-site inspection on 03/14/2022, the licensing inspector (LI) observed that the “HR Eight Hour/Shift Verification of Controlled Substance Count” document for the second floor medication cart had not been signed by the oncoming nurse which was staff 4; staff 4 had possession of the keys to the second floor medication cart during this time. When LI questioned staff 4 regarding this, staff 4 stated that she had not yet signed the document. Staff 4 then proceeded to sign the document for the oncoming nurse from 7a-7p for 03/14/2022 and also signed for the outgoing nurse for 7a-7p for 03/14/2022 which should have been signed by staff 4 when staff 4 was done performing the count with the oncoming nurse for the 7p-7a shift on this date.
  3. The “HR Eight Hour/Shift Verification of Controlled Substance Count” for the second floor medication cart was also missing the signature of the outgoing nurse for the 7a-7p shifts on 03/01/2022 and 03/11/2022.
Plan of correction
Clinical team members certified to administer medications are now correctly following the facility medication management plan. Clinical team members certified to administer medications have been educated on the facility medication management plan and appropriate processes. Director of Nursing, or designee, will conduct weekly audits of all controlled substance count documents for one month to ensure the medication management plan is being followed correctly. Executive Director, or designee, will audit all controlled substance count documents monthly to ensure continued compliance.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that the medication administration record (MAR) contained all required components.
Evidence
  1. The March 2022 MAR for resident 7 did not contain documentation of the status of his Furosemide 20 mg tab being administered nor the initials of the medication administration staff member on 3/6/2022 at 6:00 PM.
Plan of correction
Resident 7’s MAR is now being documented appropriately. Clinical team members certified to administer medications have been educated on MAR documentation and signature procedures. Director of Nursing, or designee, will conduct weekly audits of all resident MARs to ensure appropriate documentation. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident MARs to ensure continued compliance.
22VAC40-73-50-A
Based on document review, the facility failed to ensure that the statement prepared and provided to the prospective resident and his legal representative, if any, that discloses information about the facility included all required components.
Evidence
  1. The “Assisted Living Facility Disclosure Statement” provided to resident 1, admitted 02/22/2021, did not include a statement of whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
Plan of correction
Resident 1 has been provided an updated disclosure statement containing information on emergency electrical power. Sales team members have been educated on disclosure statement requirements. Director of Marketing will audit all resident admission files to ensure the correct disclosure statement has been provided to all residents. Executive Director, or designee, will audit resident files prior to admission to ensure continued compliance.
July 19, 2021Inspection1 violation
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated monitoring inspection was initiated on 7/19/2021 and concluded on 7/22/2021. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the non-compliance with standards or law, and violations can be found on the violation notice.
Violations
22VAC40-73-680-I
Based on a review of resident treatment administration records (TARs), the facility failed to ensure that all required information was documented on the MARs.
Evidence
  1. The July 2021 TARs for resident 1 does not have staff initials for the administration/application of Triaminocolone 0.1% cream to RLE, apply Exufiber AG to wound bed and cover with ABD pad on 7/9/21, 7/12/21, 7/14/21 and 7/16/21; TED Hose on the am and off at night on 7/9/21 through 7/12/21, 7/14/21 and 7/15/21 for the am application; Half side rails, Keep bed in lowest position and pressure reduction cushion on the day shift on 7/9/21 through 7/12/21, 7/14/21 and 7/15/21.
  2. The July 2021 TAR for resident 2 does not have staff initials for the application of Mepliex to the residents left and right heels on 7/16/21.
Plan of correction
1. DON and ADON will educate all Team Members on properly documenting all medications and treatments. 2. DON, ADON, or Designee will audit all MARS and TARS daily. 3. Any missed documentation will be addressed with Team Member or Agency Staff and corrected within 24 hours.
March 25, 2021Inspection6 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 3/24/21 and concluded on 3/26/21. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 35. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, Medication Management and Infection Control Policies, Fire and Health Department inspections, health care oversight, dietician review for special diets, staff schedules and fire drill logs submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-200-B
Based on a review of resident records, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training.
Evidence
  1. The record for resident 3 has a physician order dated 3/11/2021 to cleanse open area on sacrum with sacrum, gently wash and pat dry, apply Clotrimazole 1% cream and cover with Zinc Oxide three times a day for moisture associated skin damage (MASD). The March 2021 medication administration record (MAR) for resident 3 has staff person's 2, 4 and 5's initials on several days for the completion of this treatment on resident 3's sacrum. These staff persons are registered medication aides and providing routine wound care needs is outside of their scope of practice.
Plan of correction
Resident 3’s treatment is now being performed by staff persons within appropriate scope of their practice and training. Clinical leadership have been educated on which staff persons may provide certain treatments based on the scope of their practice and training. Director of Nursing, or designee, will conduct an audit of all residents receiving treatments to ensure staff persons providing care are doing so within their scope of practice. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-260-A
Based on a review of staff records, the facility failed to ensure that direct care staff received certification in first aid within 60 days of the date of their employment.
Evidence
  1. The record for staff person 1, hired on 7/16/20 and staff person 3, hired on 3/25/20, did not contain documentation that these employees have received certification in first aid since their date of employment.
Plan of correction
Staff persons 1 & 3’s first aid training has been scheduled. Clinical leadership have been educated on the requirement for direct care staff to receive certification in first aid within 60 days of hire. Director of Nursing, or designee, will audit all direct care staff files to ensure all appropriate persons are certified in first aid within 60 days of hire. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected direct care staff files to ensure continued compliance.
22VAC40-73-320-A
Based on a review of resident records, the facility failed to ensure that a history and physical was obtained within 30 days of admission to the assisted living facility.
Evidence
  1. The record for resident, readmitted to the assisted living facility on 7/2/20, did not contain documentation that a history and physical examination was completed at the time of the residents readmission.
Plan of correction
Resident 1’s History & Physical has been obtained. Clinical leadership have been educated on the requirement for History & Physicals to be obtained on readmission to the assisted living facility. Director of Nursing, or designee, will audit all resident files to ensure History & Physicals are in place for all residents. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-440-D
Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required.
Evidence
  1. The record for resident 2 has documentation in progress notes of the resident having behavior episodes on several occasions. The individualized service plan (ISP) dated 1/28/21 for resident 3 also has documentation of the resident having a history of behaviors. The UAI dated 8/20/20 in resident 3's record is inconsistent as it has that the residents behavior pattern is appropriate.
Plan of correction
Resident 2’s UAI has been updated to reflect behaviors as noted on the ISP and in progress notes. UAI trained staff have been educated on ensuring UAIs are updated when changes in behavior occur and when ISPs are revised. Director of Nursing, or designee, will audit all resident files to ensure UAIs are complete and accurate. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
22VAC40-73-450-C
Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISP).
Evidence
  1. The record for resident 1 has a physician order dated 10/1/20 for a regular diet with mechanical soft consistency. The special diet list in the facility kitchen also indicates that the resident is receiving a regular diet with mechanical soft consistency. The comprehensive ISP dated 2/10/21 in the record for resident 1 is incorrect as it has documentation that the resident is on a regular diet with regular consistency.
  2. The record for resident 3 has a physician order dated 3/11/2021 to cleanse open area on sacrum with sacrum, gently wash and pat dry, apply Clotrimazole 1% cream and cover with Zinc Oxide three times a day for moisture associated skin damage (MASD). The comprehensive ISP dated 1/27/21 for resident 3 has documentation that the resident has assessed needs for wound care but the ISP does not include the services being provided for wound care treatment order.
Plan of correction
Resident 1’s ISP has been updated to reflect a regular diet with mechanical soft consistency and Resident 3’s ISP has been updated to include the services provided for wound care. ISP trained staff have been educated on appropriate process for ensuring identified needs are addressed on ISPs. Director of Nursing, or designee, will audit all resident records to ensure accuracy of ISPs. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident charts to ensure continued compliance.
22VAC40-73-450-D
Based on review of resident records, the facility failed to ensure that the services provided by both, the assisted living facility and the licensed hospice organization, were included on the individualized service plan (ISP).
Evidence
  1. The record for resident 1 shows the resident is receiving hospice services. The comprehensive ISP for resident 1, dated 2/10/21, indicates the resident is receiving hospice services, but does not include the services provided by the hospice organization.
  2. The record for resident 3 shows the resident is receiving hospice services. The comprehensive ISP for resident 3, dated 1/27/21, indicates the resident is receiving hospice services, but does not include the services provided by the hospice organization.
Plan of correction
Resident 1 and 3’s ISPs have been updated to include services provided by the hospice organization. ISP trained staff have been educated on including specific services provided by hospice organizations on resident ISPs. Director of Nursing, or designee, will audit all hospice resident records to ensure appropriate services are noted on the ISP. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected hospice resident charts to ensure continued compliance.
March 11, 2021Inspection1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 3/11/2021 and concluded on 4/8/2021. A self- reported incident was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued.
Violations
22VAC40-73-550-C
Based on a review of facility documentation and staff interviews, the facility failed to ensure that the rights and responsibilities were provided as per 63.2-1808 of the Code of Virginia and this chapter.
Evidence
  1. On 3/8/2021 resident 1 was returning to her room from the dining room after lunch when 3 facility employees overheard staff person 1 being verbally abusive towards resident 1 in the Rotunda hallway outside of the dining room. Staff person 1 was noted to be talking loudly at resident 1 because resident 1 was expressing that she needed to sit because her legs were tired. Staff person 3 over heard staff person 1 tell resident 1 " you will walk and you can rest your legs when you get back to your room". Staff person 4 then approached resident 1 to see if she could assist the resident back to her room when staff person 1 expressed that resident 1 was giving her a hard time. Staff person 1 was suspended from work the day of the incident and after further facility investigations was terminated from employment.
Plan of correction
Staff person 1’s employment has been terminated and appropriate reporting was completed to state agencies within 24 hours of incident. Resident Rights have been reviewed with all residents. Resident Rights will be reviewed with all team members. Hermitage Roanoke leadership will provide ongoing monitoring of community to ensure rights and responsibilities of residents are upheld.
October 20, 2020Inspection3 violations
Inspection dates
Oct. 20, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 10/19/2020 and concluded on 01/12/2021. A self- reported incident was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report incident of non-compliance with standards or law, and violations were issued.
Violations
22VAC40-73-70-A
Based on a review of the record for resident 1 and other facility documentation, the facility failed to notify the regional licensing office within 24 hours of an incident that affected resident 1.
Evidence
  1. The record for resident 1 has documentation of the resident falling on 9/21/2020at 2pm sustaining a skin tear to his right elbow. A second fall is documented on 9/21/2020at 2:15pm in which resident 1 had bruises noted on his back and skin tears to his right ringer finger and left wrist. The local emergency services was contacted and resident 1 was transported and admitted to the local hospital. The facility did not notify the regional licensing office of the incidents that occurred with resident 1 or of the need for hospitalization.
Plan of correction
Facility is ensuring all incidents requiring resident transfer to hospital are being reported appropriately. All team members involved in the reporting process have been educated on the standard and appropriate reporting. Executive Director will review incident reports to ensure appropriate incidents are reported correctly.
22VAC40-73-325-B
Based on a review of resident 1's record, the facility failed to ensure that a fall risk rating was completed after a fall.
Evidence
  1. The record for resident 1 has documentation of the resident on the floor/falling on 9/18/2020 and on 9/24/2020. A fall risk rating was not completed after either of these falls. The uniform assessment instrument (UAI) dated 11/2/2019 for resident 1 has documentation that they are assessed as assisted living level of care.
Plan of correction
Facility is updating resident fall risk ratings after resident falls. Clinical team members responsible for review and updating fall risk ratings have been educated on appropriate process and regulatory guidelines. Director of Nursing, or designee, will review all fall reports to ensure fall risk ratings are updated appropriately. Executive Director, or designee, will conduct a monthly chart audit of 5 randomly selected residents who have experienced falls to ensure continued compliance.
22VAC40-73-450-C
Based on a review of the record for resident 1, the facility failed to ensure that all identified needs were addressed on the individualized service plan (ISP).
Evidence
  1. The record for resident 1 has documentation of the resident receiving physical therapy services from 5/18/20 through 8/23/2020 and again on 9/21/2020 through 10/17/2020. Occupational therapy services were noted from 9/24/20 through 10/17/20. The comprehensive ISP in the record for resident 1 does not address the identified needs for these services, when or how often these services were to be provided or any outcomes or goals to be achieved.
Plan of correction
Facility is updating resident ISPs to ensure identified needs are addressed. ISP trained staff will be educated on appropriate process for ensuring all identified resident needs are addressed appropriately on ISP. Director of Nursing, or designee, will audit all resident records to ensure all identified needs are addressed in resident ISPs. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident charts to ensure continued compliance.