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: Jan. 30, 2023

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 22VAC40-73 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

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/30/2023 8:30am until 2:30pm 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: 9 Number of staff records reviewed:6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-D
Description:	Based on record review, the facility failed to ensure that the annual training for medication aides shall include continuing education as required by the Virginia Board of Nursing. EVIDENCE: 1. The Virginia Board of Nursing?s Regulations Governing the Registration of Medication Aides, effective 02/06/2020, list that the continuing education required for registered medication aides shall consist of four hours of population-specific training in medication administration in the assisted living facility in which the aide is employed or a refresher course in medication administration offered by an approved program. 2. The record for staff 5, hired 03/25/2019, did not contain documentation that this staff member had taken four hours of population-specific training in medication administration or an annual medication administration refresher course for 2020, 2021, or 2022. 3. Interview with staff 4 could not verify that staff 5 had taken four hours of population-specific training in medication administration or an annual medication administration refresher course for 2020, 2021, or 2022.
Plan of Correction:	Staff 5 has been registered to attend an annual medication administration refresher course meeting VA Board of Nursing regulation. All Registered Medication Aides have received education on VA Board of Nursing?s annual training requirements. Director of Nursing, or designee, will audit all RMA employee files to ensure appropriate annual training has occurred. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected RMA employee files to ensure continued compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 6 has a hospice assessment noted dated 01/20/2023 for the resident to receive oxygen 2liters/min via nasal cannula continuously. The ISP for resident 6 is inconsistent as it has the use of oxygen for 8 to 20 hours during the night. Interview with staff 4 expressed that the ISP is incorrect and that resident 6 is using oxygen continuously. 2. The record for resident 9 has documentation of a physician order 07/20/2022 for a protective brace to left hand one time a day for severe thumb arthritis at CMC, MCP and JP joints. The ISP in the record for resident 9 does not address this identified need.
Plan of Correction:	Resident 6?s ISP has been updated to reflect continuous oxygen use. Resident 9?s order for a protective brace to left hand has been discontinued and the ISP reflects this change. ISP trained team have been educated on ensuring identified needs are addressed on each resident?s ISP. 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 #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. EVIDENCE: 1. The ISP for resident 1, dated 12/30/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative. 2. The ISP for resident 2, dated 12/15/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative. 3. The ISP for resident 3, revised on 01/03/2023, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative. 4. The ISP for resident 6, revised 02/25/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative. 5. The ISP for resident 9, revised on 04 13/2022, did not contain a signature and date of completion by the person who developed the plan nor the resident or his legal representative.
Plan of Correction:	ISPs for Residents 1, 2, 3, 6, and 9 have been signed by the person who developed the plan and the resident or their legal representative. ISP trained team have been educated on ensuring all ISPs are signed by the person who developed the plan and the resident or their legal representative. Director of Nursing, or designee, will audit all resident files to ensure ISPs are signed by appropriate persons. 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 record review and observation, the facility failed to implement its medication management plan, specifically regarding methods to ensure that each resident?s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. EVIDENCE: 1. The facility?s Medication Management Plan (revised 5/2022) states the following: ?Adequate supplies of medications will be maintained at the facility. A refill request will be sent to the pharmacy when a 5-day supply remains to allow for timely refill of the prescription. New resident?s orders will be entered electronically and pharmacy will be contacted to ensure orders received.? 2. The record for resident 7 contained physician?s orders, signed 01/01/2023, which included Donepezil HCl Tablet 10 MG ?Give 1 tablet by mouth at bedtime related to unspecified Dementia without behavioral disturbance?. 3. Progress notes for resident 7 indicate that the facility was waiting for Donepezil HCl Tablet 10 MG to be delivered by the pharmacy on 01/01/2023, 01/02, 01/03, 01/04, 01/07, 01/08, 01/11, 01/16, 01/17, and 01/18/2023. The January 2023 MAR for resident 7 indicates that this medication was not administered on those dates.
Plan of Correction:	Clinical team members certified to administer medications are following the facility medication management plan as it relates to filling and refilling medications. Clinical team members certified to administer medications have been educated on the facility medication management plan and appropriate processes for filling and refilling medications. Director of Nursing, or designee, will conduct weekly audits of all medication carts for one month to ensure the medication management plan is being followed correctly. Executive Director, or designee, will audit one randomly selected medication cart monthly to ensure continued compliance.
Standard #:	22VAC40-73-650-C
Description:	Based on resident record review, the facility failed to ensure that orders were signed by a residents physician within 14 days. EVIDENCE: 1. The record for resident 5 has an electronic physician order dated 01/04/2023 for Vitamin D 50mcg by mouth daily. The order does not contain the signature of the resident physician as of the date of inspection.
Plan of Correction:	Resident 5?s order for Vitamin D 50mcg by mouth daily has been signed by the physician. Nursing leadership has been educated on ensuring all orders are appropriately signed by the residents? physician. Director of Nursing, or designee, will audit all resident files to ensure orders are signed by appropriate physician. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations of the facility physical plant, the facility failed to ensure that medications prescribed to residents were stored in a locked area. EVIDENCE: 1. The second floor nursing station was observed to be unlocked and unattended at 9:24am on the day of inspection. Two bags labeled ?Pharmacy Return? were observed sitting out on the cabinet beside the copy/fax machine. The bags contained numerous medications for multiple residents.
Plan of Correction:	All nurses? stations are locked and appropriate team have keys for access. Clinical team members have been educated on ensuring all nurses? station doors remain locked. Director of Nursing, or designee, will perform daily checks for one month to ensure nurses? station doors are appropriately locked. Executive Director, or designee, will conduct weekly audits for one month to ensure all nurses? station doors remain locked.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. The second floor laundry was noted to be unlocked on the day of inspection. The lower cabinet to the right was observed to be unlocked and contained a bottle of Dispatch Hospital Cleaner/Disinfectant towels with Bleach, a bottle of Clorox Bleach Germicidal cleaner and a bottle of Envirox Carpet Sport and Stain Remover. 2. The second floor nursing station was observed to be unlocked and unattended on the day of inspection. A bottle of Dispatch Hospital Cleaner/Disinfectant towels with Bleach was sitting out on the counter by the sink and a bottle of Hydrogen Peroxide was observed in the unlocked cabinet above the sink. 3. The second floor pantry was observed unlocked on the day of inspection. A bottle of Champion Spray Disinfectant and a bottle of Pine-sol was observed in the unlocked lower cabinet under the microwave and sink.
Plan of Correction:	Cleaning supplies found in the second floor laundry, nurses? station, and pantry have been appropriately stored in a locked area. Team members have been educated on ensuring all cleaning supplies are stored in a locked area. Director of Nursing, or designee, will perform daily rounds for one month to ensure cleaning supplies are stored appropriately in a locked area. Executive Director, or designee, will conduct weekly rounds for one month to ensure continued compliance.