1 Inspection Summary
Inspection Reports Summary
Covers 14 inspections · Oct 2020 – Feb 2026Visit Reason
The page covers 14 inspections of Hermitage Roanoke from October 20, 2020 to February 18, 2026, including routine, renewal, monitoring, and complaint investigations.
Complaint Details
One inspection was prompted by a complaint received on 04/14/2022 regarding administration, personnel, staffing and supervision, admission, retention and discharge of residents, resident care and related services, and building and grounds. The investigation supported some allegations and violations were cited.
Findings
Across that history VDSS cited 43 violations under 32 distinct standards. 13 of 14 visits cited violations and 1 was clean. One inspection was prompted by a complaint.
Violations (45)
22VAC40-73-860-I: Facility failed to store cleaning supplies and hazardous materials in a locked area.
22VAC40-73-1040-A: Facility failed to ensure door alarms for residents with serious cognitive impairments were properly monitored and functional.
22VAC40-73-450-F: ISP not reviewed and updated for significant change in resident condition.
22VAC40-73-440-A: Uniform assessment instrument not updated for significant change in resident condition.
22VAC40-73-1030-B: Direct care staff did not complete required six hours of cognitive impairment training within four months of hire.
22VAC40-73-680-M: Medications ordered for PRN administration were not available, properly labeled, or stored.
22VAC40-73-990-C: Staff failed to participate in resident emergency procedure drills at least every six months.
22VAC40-73-410-A: Facility failed to provide signed and dated orientation documentation for a new resident.
22VAC40-73-700-1: Physician’s order for oxygen did not contain oxygen source and delivery device.
22VAC40-73-450-D: Hospice services were not included on the individualized service plan.
22VAC40-73-350-B: Facility failed to ensure sex offender screening was completed prior to admission.
22VAC40-73-450-E: ISPs were not signed and dated by licensee, administrator, or resident/legal representative.
22VAC40-73-650-C: Physician orders were not signed within 14 days.
22VAC40-73-450-C: Identified needs were not addressed on individualized service plans.
22VAC40-73-640-A: Facility failed to implement medication management plan to ensure timely filling and refilling of medications.
22VAC40-73-660-A-1: Medications prescribed to residents were not stored in a locked area.
22VAC40-73-210-D: Medication aides did not receive required continuing education annually.
22VAC40-73-680-D: Medications were not administered in accordance with physician instructions.
22VAC40-73-450-E: ISPs were not signed and dated by licensee, administrator, or resident/legal representative.
22VAC40-73-860-I: Cleaning supplies were not stored in a locked area.
22VAC40-73-450-C: Identified needs were not addressed on individualized service plans.
22VAC40-73-680-I: Medication administration records lacked required documentation and staff initials.
22VAC40-73-930-B: Signaling device was not continuously staffed and did not permit staff to determine origin of signal.
22VAC40-73-680-D: Medications were not administered in accordance with physician instructions.
22VAC40-73-450-F: ISPs were not updated when a change in resident occurred.
22VAC40-73-640-A: Facility failed to implement medication management plan.
22VAC40-73-660-B: Residents capable of self-administering medication had medications stored in their rooms without proper documentation.
22VAC40-73-680-G: Over-the-counter medication was not labeled with resident’s name.
22VAC40-73-450-C: Comprehensive individualized service plans were incomplete or inaccurate.
22VAC40-73-440-D: Uniform assessment instrument was not completed as required.
22VAC40-73-680-B: Medications were not kept in pharmacy issued container with proper labels until administered.
22VAC40-73-100-C-2: Infection control policies consistent with CDC recommendations were not followed.
22VAC40-73-680-I: Medication administration records lacked required components.
22VAC40-73-50-A: Disclosure statement to prospective resident lacked required information about emergency electrical power.
22VAC40-73-200-B: Direct care staff provided services outside scope of practice and training.
22VAC40-73-260-A: Direct care staff did not receive first aid certification within 60 days of employment.
22VAC40-73-320-A: History and physical was not obtained within 30 days of admission.
22VAC40-73-440-D: Uniform assessment instruments were not completed as required.
22VAC40-73-450-C: Identified needs were not addressed on individualized service plans.
22VAC40-73-450-D: Services provided by assisted living and hospice were not included on individualized service plans.
22VAC40-73-680-I: MARs lacked staff initials for medication and treatment administration.
22VAC40-73-680-I: MARs lacked staff initials for medication and treatment administration.
22VAC40-73-680-D: Medications were not administered in accordance with physician instructions.
22VAC40-73-450-C: Identified needs were not addressed on individualized service plans.
22VAC40-73-450-E: ISPs were not signed and dated by licensee, administrator, or resident/legal representative.
Report Facts
Violations cited: 43
Distinct standards: 32
Inspections on page: 14
Inspections with violations: 13
Complaint visits: 1
Employees mentioned
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