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: May 11, 2022

Complaint Related: Yes

Areas Reviewed:

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 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:

Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	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.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	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.
Standard #:	22VAC40-73-930-B
Complaint related:	No
Description:	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.