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 14, 2022

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.

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:

Standard #:	22VAC40-73-100-C-2
Description:	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.
Standard #:	22VAC40-73-50-A
Description:	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: 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.
Standard #:	22VAC40-73-440-D
Description:	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.
Standard #:	22VAC40-73-450-C
Description:	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.
Standard #:	22VAC40-73-640-A
Description:	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.
Standard #:	22VAC40-73-660-B
Description:	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.
Standard #:	22VAC40-73-680-B
Description:	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.
Standard #:	22VAC40-73-680-G
Description:	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: 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.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that the medication administration record (MAR) contained all required components. EVIDENCE 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.