VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hermitage Roanoke
1009 Old Country Club Road, N.W.
Roanoke, VA 24017
(540) 767-6800

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: March 12, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

The LI for The Hermitage conducted an unannounced renewal study at the facility on 3/12/2020 from 8:30am until 2:30pm in conjunction with another LI and noted 46 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed. Interviews were conducted with residents and staff. A tour of the physical plant was conducted and the morning medication pass and mid day meal was observed. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. Please respond back to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions, please contact your licensing inspector at 540-.309-2968

Violations:

Standard #:	22VAC40-73-50-B
Description:	Based on a review of resident records, the facility failed to retain written acknowledgement of the receipt of the facility disclosure in resident records. EVIDENCE: 1. The record for resident 1 admitted on 1/22/20 and resident 2 admitted on 9/26/19 did not contain written acknowledgement of the residents reciving the facility disclosure statement.
Plan of Correction:	Resident 1 and 2 have signed acknowledgement of receipt of the disclosure statement. Admissions team has been educated on necessity of documented receipt of the disclosure statement. Admissions team will audit all resident files to ensure signed acknowledgement of the disclosure statement is filed appropriately. Executive Director, or designee, will audit new admission files to ensure signed acknowledgement of disclosure statement is filed appropriately.
Standard #:	22VAC40-73-120-A
Description:	Based on staff record review, the facility failed to ensure that a new staff person had required orientation within seven days of hire. EVIDENCE: 1. The record for staff person 4, employed on 3/11/19 did not have documentation to support that new staff orientation had been completed within the first seven working days for this employee.
Plan of Correction:	Staff person 4?s orientation documentation has been updated appropriately. HR team has been educated on necessary documentation of orientation within 7 days of hire. Business Office Manager, or designee, will conduct a full audit of employee files to ensure compliance with this standard.Executive Director, or designee, will conduct a monthly audit of 5 randomly selected employee files to ensure continued compliance.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to ensure that a staff file had verification that the staff person received a copy of his current job description. EVIDENCE: 1. The record for staff person 4, hired on 3/11/19, lacked acknowledgement that the staff person received a copy of his current job description.
Plan of Correction:	Staff person 4?s acknowledgement of job description has been filed appropriately. HR team has been educated on necessary documentation of acknowledgement of job description. Business Office Manager, or designee, will conduct a full audit of employee files to ensure compliance with this standard. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected employee files to ensure continued compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that all required information was obtained with employee tuberculosis screenings. EVIDENCE: 1. The tuberculosis screenings completed in April 2019 for staff persons 2 and 4 and the tuberculosis screening completed in August 2019 for staff person 3 did not have the name/signature of the person who is qualified to complete/review the screening.
Plan of Correction:	Staff persons 2, 3, and 4?s TB screenings have been updated to include the name/signature of the person who is qualified to complete the screening. HR team has been educated on necessity for TB screenings to have appropriate names/signatures. Business Office Manager, or designee, will conduct a full audit of employee files to ensure compliance with this standard. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected employee files to ensure continued compliance.
Standard #:	22VAC40-73-270-1
Description:	Based on a review of staff records, the facility failed to ensure that employees received training in aggressive behavior to include information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior prior to caring for residents. EVIDENCE: 1. The training records for staff persons 1 and 2 has documentation that the employees have received training on aggressive behaviors thru an on-line training but there is no documentation of training to include demonstration and practical experience in self protection for residents who have aggressive behaviors. During a review of resident records, it was noted that resident 5 has a history of aggressive behaviors.
Plan of Correction:	Staff persons 1 & 2 have received training on aggressive behaviors, including demonstration and practical experience. Clinical leadership have been educated on required aggressive behavior training, demonstration, and practical experience. Business Office Manager, or designee, will conduct a full audit of all employee files to ensure compliance with this standard. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected employee files to ensure continued compliance.
Standard #:	22VAC40-73-310-B
Description:	Based on a review of resident records, the facility failed to ensure documentation of a interview prior to admission for determination that the facility can meet the residents needs. EVIDENCE: 1. The record for resident 1 admitted on 1/22/20 and resident 2 admitted on 9/26/19 did not contain documentation of an interview comlete with the residents prior to admission.
Plan of Correction:	Facility is now documenting interviews with new residents prior to admission to determine needs can be met. Admissions team has been educated on necessity for documentation of interviews prior to admission to ensure needs can be met. Executive Director, or designee, will audit new admission files to ensure documentation of preadmission interview.
Standard #:	22VAC40-73-410-A
Description:	Based on a review of resident records, the facility failed to ensure residents signed for acknowledgement of receiving an orientation to the facility at the time of admission. EVIDENCE: 1. The record for resident 1 admitted on 1/22/20 and resident 2 admitted on 9/26/19 did not contain acknowledgement of the resident receiving an orientation to the facility at the time of admission.
Plan of Correction:	Residents 1 and 2 have received orientation to the community. Admission documentation has been updated to clearly show orientation of new residents to the community. Executive Director, or designee, will audit new admission files to ensure documentation of orientation to the community.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The UAI dated 2/18/20 in the record for resident 2 did not have the signature of the administrator or designee at the time the UAI was completed. 2. The record for resident 5 has documentation of the resident having aggressive behaviors and a diagnosis of vascular dementia with behavioral disturbance. The UAI dated 12/5/19 for resident 5 is inconsistent as it has the resident behavior pattern as appropriate.
Plan of Correction:	The UAI for resident 2 has been signed by the administrator and the UAI for resident 5 has been updated to reflect aggressive behavior. UAI trained staff will be reeducated on appropriate documentation and importance of accuracy. Director of Nursing, or designee, will audit all resident records to ensure accuracy of UAIs. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident charts to ensure continued compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on residents comprehensive individualized service plans (ISPs). EVIDENCE: 1. The History and Physical dated 12/11/19 for resident 1 has documentation of a physician order for physical and occupational therapy. The record also has documentation of therapy notes for services that the resident received from 12/27/19 through 3/6/2020. The ISP dated 12/20/19 does not address this identified need. 2. The record for resident 6 has documentation that the resident receives mental health services. The ISP dated 2/24/20 does not address this identified need. 3. The record for resident 5 has documentation of the resident having aggressive/abusive behaviors on 2/21/20, 3/5/20 and 3/12/20. The progress notes also have documentation of a diagnosis of vascular dementia with behavioral disturbances. The ISP dated 12/5/19 does not address this identified need.
Plan of Correction:	Resident 1?s ISP has been updated to reflect therapy orders, resident 6?s ISP has been updated to address mental health services, and resident 5?s ISP has been updated to show aggressive behavior and vascular dementia with behavioral disturbances. ISP trained staff will be reeducated on appropriate process for ensuring completeness and accuracy. 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.
Standard #:	22VAC40-73-660-A-7
Description:	Based on observations made of the facility medication carts, the facility failed to ensure that dedicated medical equipment was appropriately labeled. EVIDENCE: 1. Medication cart A3 had a bag labeled for resident 10 but the glucometer inside the bag did not contain the residents name.
Plan of Correction:	Glucometer for resident 10 has been labeled. Clinical team members who have access to the medication carts have been educated on appropriate labeling of glucometers. Director of Nursing, or designee, will audit all glucometers to ensure labeling. Executive Director, or designee, will audit all glucometers weekly for one month and then as needed to ensure continued compliance.
Standard #:	22VAC40-73-660-B
Description:	Based on observations and document review, the facility failed to ensure that medication stored in a resident room was stored in an out-of-sight manor by a resident who was able to self-administer medications. EVIDENCE: 1. Resident 11?s room had Afrin Nasal Spray, Dulcolax tablets, Imodium, and Genteal eye drops stored in several visible places in her apartment. The uniform assessment instrument (UAI) for resident 11 dated 4/23/2019 showed this resident is unable to self-administer medication. There are no orders in the resident record to show that these medications can be given by staff or the resident.
Plan of Correction:	Medications have been removed from resident 11?s room and resident 11 has been educated on medication administration policies. Director of Nursing, or designee, will audit all resident apartments to ensure medications are stored properly. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident apartments to ensure continued compliance.
Standard #:	22VAC40-73-680-B
Description:	Based on observation of the facility medication carts, the facility failed to have a medication in a pharmacy container with the prescription label attached. EVIDENCE: 1. Latanoprost (a prescription medication) in cart A3 was not labeled with a resident name, and had no prescription label. Staff 3 said it belonged to resident 9.
Plan of Correction:	The Latanoprost for resident 9 has been labeled appropriately with the prescription label. Clinical team members who have access to the medication carts have been educated on appropriate labeling of medications. Director of Nursing, or designee, will audit all medication carts to ensure appropriate labeling of medications. Executive Director, or designee, will audit all medication carts weekly for one month and then as needed to ensure continued compliance.