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: Feb. 28, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 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:

Standard #:	22VAC40-73-350-B
Description:	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.
Standard #:	22VAC40-73-410-A
Description:	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.
Standard #:	22VAC40-73-450-D
Description:	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.
Standard #:	22VAC40-73-700-1
Description:	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.
Standard #:	22VAC40-73-990-C
Description:	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.