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: Oct. 20, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 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 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:

Standard #:	22VAC40-73-70-A
Description:	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.
Standard #:	22VAC40-73-325-B
Description:	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.
Standard #:	22VAC40-73-450-C
Description:	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.