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: July 19, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated monitoring inspection was initiated on 7/19/2021 and concluded on 7/22/2021. 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 non-compliance with standards or law, and violations can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based on a review of resident treatment administration records (TARs), the facility failed to ensure that all required information was documented on the MARs. EVIDENCE: 1. The July 2021 TARs for resident 1 does not have staff initials for the administration/application of Triaminocolone 0.1% cream to RLE, apply Exufiber AG to wound bed and cover with ABD pad on 7/9/21, 7/12/21, 7/14/21 and 7/16/21; TED Hose on the am and off at night on 7/9/21 through 7/12/21, 7/14/21 and 7/15/21 for the am application; Half side rails, Keep bed in lowest position and pressure reduction cushion on the day shift on 7/9/21 through 7/12/21, 7/14/21 and 7/15/21. 2. The July 2021 TAR for resident 2 does not have staff initials for the application of Mepliex to the residents left and right heels on 7/16/21.
Plan of Correction:	1. DON and ADON will educate all Team Members on properly documenting all medications and treatments. 2. DON, ADON, or Designee will audit all MARS and TARS daily. 3. Any missed documentation will be addressed with Team Member or Agency Staff and corrected within 24 hours.