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Our Lady of the Valley
650 N. Jefferson St
Roanoke, VA 24016
(540) 345-5111

Current Inspector: Julie Ferguson (540) 204-9629

Inspection Date: Jan. 24, 2013 and Jan. 28, 2013

Complaint Related: No

Areas Reviewed:
22VAC40-72 ADMINISTRATION AND ADMINISTRATIVE SERVICES.
22VAC40-72 PERSONNEL.
22VAC40-72 STAFFING AND SUPERVISION.
22VAC40-72 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
22VAC40-72 RESIDENT CARE AND RELATED SERVICES
22VAC40-72 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS.
22VAC40-72 BUILDINGS AND GROUNDS.
22VAC40-72 EMERGENCY PREPAREDNESS.

Technical Assistance:
Requirements for Standards 22 VAC 40 -72- 930 and 970 ( recites) were reviewed and discussed with administration for compliancy.

Comments:
A focused follow-up inspection was conducted at Our Lady of the Valley Assisted Living Facility on January 24 and January 28, 2013 finding 85 residents in care. Prior violations were addressed with recites in eight standards. A tour of the physical plant was taken per previous cited areas and two separate medication passes were observed. Resident and staff records were reviewed as well as various forms of required facility documentation. Findings of the inspection were discussed on the days of inspection and risk assessments were shared on February 1, 2013.

Violations:
Standard #: 22VAC40-72-630-A
Description: Based on observations during the inspection on 1/2/2013, the facility failed to follow the medication management policy which addresses procedures to ensure the proper administration of medications. Evidence: 1. A bottle of Humulin R 100 was stored in the medication cart for Resident # 23. The resident has the use of Humulin ordered on a Sliding Scale for blood sugars over 200. The bottle was opened and there is documentation of the medication being administered X 3. The bottle has a label stating " Refrigerate" and the 2013 Nursing Drug Handbook also advises to refrigerate or store in a cool place at the least. The medication also did not contain an " opened" date. 2. Levemir 100 units, filled 11/20/2012 was stored in the facility's medication refrigerator on the first day of inspection for Resident # 24. The resident had had an order for the medication, inject 50 units subcutaneously every morning for Diabetes, but the order was changed and the resident has not been on this medication since being hospitalized on 12/9/2012. Resident # 24 returned to the facility on 12/17/2012 with new orders and the facility had failed to dispose of this medication. 3. Resident # 17 leaves the facility for Dialysis on Mondays, Wednesdays and Fridays. The facility is sending the noon time medication, Midodrine HCL 10 mg , with the resident in a small plastic bag. Regulation mandates that all medications shall remain in the pharmacy issued container with the legible prescription label attached until administered. 4. Isosorbide 30 mg, one tablet prescribed daily for Resident # 8 was not available on the morning of inspection for administration. The pharmacy issued container was empty. Medication administration staff had to secure a dose from an emergency supply to administer to the resident who received the medication later than the standard dosing time frame. 5. Resident # 27 has an order dated 6/22/2012 for PEG 3350 and written on the January, 2013 MAR for 17 grams every other day, hold for loose stools. The bottle of medication observed on the facility cart, filled 12/28/2012 has directions to give 17 grams daily The facility is administering the medication according to current orders, but the label on the bottle of medication contains inaccurate instructions.

Action to be Taken: ? Medication for Resident #23 reordered. Pharmacy confirmed with package insert that medication does not have to be refrigerated so pharmacy will not mark with a refrigerator tag. Staff will be educated to refrigerate insulin until opened and to mark the date opened clearly on the bottle. 100% audit completed on all insulin to ensure the date opened is clearly marked on the label. ? Medication for Resident #24 was sent back to pharmacy. Medication refrigerator and carts will be audited daily by floor staff and weekly by unit manager to ensure all discontinued medications are sent back to pharmacy timely. ? Medication for Resident #17 ordered from pharmacy as leave of absence medication. Order clarified and medication will be package appropriately for resident to take to dialysis. Staff education on medication administration policy and procedure completed with nurses and registered medication aides. ? Medication for resident #8 ordered. Staff education on staying in compliance with medication administration time. ? Medication for resident #27. Staff education on checking medications 3 times before administering medication. Staff instructed to send medications that are changed back to the pharmacy for repackaging or so the pharmacy can resend the medication with the proper labels. ? 100% audit done of medication carts, orders and medication administration records. Corrections to be made as needed. ? Assisted living regulation reviewed with staff. ? Staff education on medication management plan and medication administration policy and procedure completed with nurses and registered medication aides. ? Medication carts, medication administration records and resident charts will be audited weekly and randomly for compliance by the unit manager or designee. ? DON or designee will audit monthly and as needed.

Standard #: 22VAC40-72-640-A
Description: Based on review of the medication administration records, resident records and discussion with staff on duty during the inspection, the facility failed to obtain a physician's order before changing the way a medication is administered to the resident or when a medical procedure is to be performed. Evidence: 1. Antacid Chewables 500 mg take three tablets ( 1500 g) by mouth daily for supplement ( 9 am) is prescribed for Resident # 9 since 8/23/2012. The facility wrote in an additional 1 pm dosage time and a 5 pm dosage time and have been administering one tablet three times a day instead of the three tablets at one dosage time as ordered without obtaining a valid order from the physician to change the way the medication is administered to the resident. 2. All morning medications for Resident # 10 were crushed and placed in applesauce without a valid order to place the medications in food from the physician. 3. All morning medications for Resident # 11 were crushed and placed in applesauce without a valid order to place the medications in food from the physician. 4. Blood pressures every week on Sunday is ordered for Resident # 2. Per review of the January, 2013 MAR, there was no blood pressure taken on Sunday, 1/13/2013, but a record of a blood pressure taken on Monday 1/14/2013 is documented on the January, 2013 MAR for this resident.

Action to be Taken: ? Medication for resident #9 clarified to take one tab three times a day. Mars will be checked monthly by two nurses to ensure accuracy. Staff educated on checking medications 3 times before administering medication. Staff educated on clarifying orders as needed to ensure accurate dosing. ? Medications for resident #10 and #11 clarified to have an order to crush medications and place in assorted foods for administration. 100% audit completed on all residents receiving meds crushed or with food and orders obtained if needed to administer medications with assorted foods and crush if needed. Staff educated to only crush medications or put in food if the resident has an order to do so. ? Blood pressure for resident #2 are to be taken weekly on Sunday. A reminder was placed in the front of the mar. Staff educated on following the physician order as written. ? 100% audit done of medication carts, orders and medication administration records. Corrections to be made as needed. ? Assisted living regulation reviewed with staff. ? Staff education on medication management plan and medication administration policy and procedure completed with nurses and registered medication aides. ? Medication carts, medication administration records and resident charts will be audited weekly and randomly for compliance by the unit manager or designee. ? DON or designee will audit monthly and as needed.

Standard #: 22VAC40-72-650-B
Description: Based on observation during the physical plant tour, the facility failed to ensure that medications stored in residents' rooms are secured and not accessible to other residents, and that the uniform assessment instrument has indicated that the resident is capable of self-administering medication. Evidence: 1. Observed in Room 301 was a bottle of Chlorhexidene Gluconate by the bed closest to the door. By the 2nd bed Dovonex .005 % cream was observed. 2. In Room 225 Antacid Tablets were observed sitting out on the resident's night stand by the bed. 3. In Room 205 the following were observed: Glycerin Laxatives, PED 3350 Glycol 3350 Powder, 3 Glucerna Shakes, 2 tubes of Desitin, a tube of A & D Ointment, Tums, and two bottles of Vitamins belonging to the personal caregiver sitting on a shelf in the hallway entering the room. ( Note: Gkucerna Shakes that were ordered for a supplement for Resident # 3 were discontinued on 4/18/2012)

Action to be Taken: ? Room 301 and 225 staff and residents educated on keeping medications secure. ? Room 205 medications removed from room. Medication will be given by staff. ? Rounds daily by floor staff to ensure medications are secure. Weekly rounds by unit manager to ensure medications are secure. ? Assisted living regulation reviewed with staff. ? All staff was educated on the self-administration and medication administration policy as well as the need to monitor resident apartments to ensure that medications are maintained in proper storage. ? 100% audit of AL rooms for medications performed with corrections made. Family will be notified to bring all medications including over the counter medications to the nurse for physician approval and proper storage. ? Administrator, DON or designee will audit monthly and as needed.

Standard #: 22VAC40-72-670-B
Description: Based on observation during the morning medication pass, the facility failed to administer medications not later than one hour after the facility's standard dosing schedule. Evidence: 1. Resident # 14 received all 9 am medications at 10:20 am. 2. Resident # 8 received their Timolol 0.5. % eye drops scheduled for 8 am at 9:20 am. 3. Resident # 15 received their Levetiracetam scheduled for 8 am at 9:25 am. 4. Resident # 18 received all 8 am medications at 9:45 am. 5. Resident # 19 received all 8 am medications at 9:50 am. 6. Resident # 16 received their 8 am dose of Lasix 20 mg at 9:10 am. 7. Resident # 20 received all 9 am medications at 10:15am. 8. Resident # 25 received all 9 am medications at 10:20 am.

Action to be Taken: ? Staff educated to complete their med pass before allowing a person monitoring or inspecting the med pass to be allowed to take the MAR from the cart. Staff educated on importance of staying focused and not allowing distractions to get them behind and out of compliance. ? Staff education on medication administration policy and procedure completed with all nurses and registered medication aides. ? Assisted living regulation reviewed with staff. ? Medication times adjusted to ensure time permits compliance. ? Mars will be checked monthly by two nurses to ensure accuracy. ? Medication observations will be done randomly and monthly for compliance. ? Administrator, DON or designee will be responsible for medication observations.

Standard #: 22VAC40-72-670-C
Description: Based on review of the January, 2013 MAR, the facility failed to administer medications in accordance with the physician's instruction and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident # 5 has an order for 5 mg of Coumadin to be administered on Monday, Tuesday, Thursday, Friday and Saturdays for A-Fib. There is no documentation of the medication being administered as ordered on Monday, 1/21/2013 at 5 pm as ordered. An audit of the medication cart shows the medication still intact in the medication storage container issued by the pharmacy for this date.

Action to be Taken: ? Education on medication administration policy and procedure completed with nurses and registered medication aides. ? Assisted living regulation reviewed with staff. ? Medication aide that did not give the medication educated individually. ? Medication administration records to be checked by charge nurse at the end of each shift for discrepancies. ? Medications administration records will be audited weekly and randomly for compliance by the unit manager. ? DON or designee will audit monthly and as needed.

Standard #: 22VAC40-72-670-E
Description: Based on observation during an audit of the facility's medication storage, the facility failed to ensure that sample medications be labeled by a physician or pharmacist with the resident's name, name of the medication, strength, dosage, rout and frequency of administration , until administered. Evidence: A container of Lumigan, Bimatoprost Opthalmic Solution, 0.01 %, 2.5 ml. professional sample was observed stored with the last name of a resident on it that did not contain the required labeling.

Action to be Taken: ? Staff educated to send sample meds with the order to pharmacy for proper labeling. ? 100% audit done of medication carts, orders and medication administration records. Corrections to be made as needed. ? Medication carts, medication administration records and resident charts will be audited weekly and randomly for compliance by the unit manager or designee. ? Staff education on medication management plan and medication administration policy and procedure completed with nurses and registered medication. ? Assisted living regulation reviewed with staff.

Standard #: 22VAC40-72-670-H
Description: Based on a review of the January 2013 MAR ( medication administration records), the facility failed to document medications administered to residents, Evidence: 1. Namenda 5 mg, one two times a day for memory is prescribed for Resident #1. There are no initials to support administration at the 9 pm dosage on 1/23/2013. 2. Glipizide 10 mg, Dorzolamide HCL 2 % ey drops, Simvastatin 20 mg, Famotidine 20 mg , Alphagan 1 % eye drops and Lumigan 0.03 % eye drops all lack initials to support administration on 1/13/2013 during the evening shift for Resident # 2. Glipizide 10 mg, Metformin HCL 500 mg, Dorzolamide HCK 2 % eye drops also lack documentation of administration at 5 pm on 1/21/2013 for this resident. 3. Ativan 2 mg, one tablet four times daily is shown as discontinued on the January, 2013 MAR for Resident # 3 without documenting the date the medication was discontinued. Morphine Sulfate 100 mg/5 ml, give 0.25 ml every 2 hours while awake, and give 0.5 ml every 2 hours as needed for breakthrough pain for Resident # 3 has "discontinued" written on the MAR without documentation of the date the physician discontinued the order. Morphine Sulfate 0.5 mg is documented as administered on 1/2/2013 at 3 : 55 am without noting the results/response of the medication. Robitussin DM 5 mls every 6 hours as needed for cough is documented as administered on 1/20/13 at 5:30 am and on 1/22/13 at 2:15 pm for cough without documenting the effectiveness of the medication for Resident # 3. Ativan 2 mg lacks initials to support administration at 11 pm on 1/13/2013 for Resident # 3. Systane eye drops 0.4%, one drop into both eyes three times a day lacks documentation of administration at 7 pm on 1/22/2013 for Resident # 3. Ativan 2mg one four times a day, ordered on 1/21/2013 lacks a diagnosis for administration and documentation of administration at 12 am on 1/22/2013 for Resident # 3. 4. Mucinex 600 m one every 12 hours prescribed for Resident # 4 lacks initials to support administration on 1/17/2013 at 8 pm. Lyrica 150, one capsule three times a day for backache lacks documentation of administration at 9 pm on 1/22/2013 for this resident. 5. Deoneb 2.5-0.5 mg, inhale contents of 1 unit dose vial via nebulizer 3 times a day for COPD lacks initials to support administration at 9 pm on 1/17/2013 for Resident # 5. The 8 am dose for 1/24/2013 is not initialed as administered when the MAR was reviewed at 10:30 am. 6. Tylenol 325, two tablets ( 650 mg) every four hours as needed for pain , prescribed for Resident # 6, is initialed as administered on 1/22/2013 with no documentation on the back of the MAR ( or other MARs for this resident) for date and time administered, dosage, symptoms or effectiveness, or include the signature of the medication administration staff person. 7. Lomotil , to be taken every morning before breakfast is prescribed for Resident # 7. There are no initials to support administration on 1/19/2013 at 6:30 am. 8. Montelokast 10 mg, one daily is prescribed for Resident # 8 and lacks initials to support administration on 1/11/2013 at 9 am. 9. Hydrazaline 10 mg daily for Hypertension prescribed on 1/16/2013 lacks documentation of administration on 1/22/2013 at 9 am for Resident # 13.

Action to be Taken: ? Staff education on medication administration policy and procedure completed with nurses and registered medication aides ? Assisted living regulation reviewed with staff. ? Medication aides and nurses that had lacking documentation educated individually. ? Medications administration records to be checked by charge nurse at the end of each shift for discrepancies. ? Medications administration records will be audited weekly and randomly for compliancy by the unit manager. ? DON or designee will audit monthly and as needed.

Standard #: 22VAC40-72-670-K
Description: Based on observation of medication stored in the facility's medication cart, the facility failed to ensure that medications ordered for PRN administration be properly labeled for the specific resident and properly stored at the facility. Evidence: PEG 3350 stored for Resident # 26 has a label that states " give 17 grams two times daily." The medication was changed to "as needed ( PRN)" on 1/11/2013 but the facility failed to have the medication properly labeled according to current physician's orders.

Action to be Taken: ? Medication for resident #26: Staff education on checking medications 3 times before administering medication. Staff instructed to send medications that are changed back to the pharmacy for repackaging or so the pharmacy can resend the medication with the proper labels. ? 100% audit done of medication carts, orders and medication administration records. Corrections to be made as needed. ? Staff education on medication management plan and medication administration policy and procedure completed with nurses and registered medication. ? Assisted living regulation reviewed with staff. ? Medication carts, medication administration records and resident charts will be audited weekly and randomly for compliance by the unit manager or designee. ? DON or designee will audit monthly and as needed.

Standard #: 22VAC40-72-840-I
Description: Based on observation upon arrival to the facility and during the physical plant tour, the facility failed to keep cleaning supplies and other hazardous material stored in a locked area. Evidence: 1. Observed upon arrival at 8:30 am to the facility , a housekeeping cart was observed in the 2nd floor hallway off of the entrance lobby that was unlocked, unattended and out of site of the staff person responsible that contained numerous cleaning chemicals. 2. At 10:45 am, a housekeeping cart was observed on the second floor that was unlocked and unattended left out in the hall outside resident rooms. The cart contained Disinfectant Spray, Tough Duty Industrial Strength All Purpose Cleaner and De greaser; TB-Cide Cleaner/Deodorizer/Disinfectant; Airlift Cranberry Ice Deodorant; Febreeze Glistening Alpine; Lysol AP Cleaner, Raid Ant and Roach, and Lysol Deodorizing Spray. When the facility staff exited the room, the L.I. discussed the regulation that all cleaning supplies must be locked and the staff person stated the lock was not operational on the cart and that they had informed their supervisor. 3. The Maintenance Office was unlocked with the door standing open as observed on the second day of inspection with the accessibility of numerous hazardous chemicals stored in view. The Director of Nursing was alerted and the office was locked immediately. The facility houses residents with a mental health diagnosis and cognitive impairments.

Action to be Taken: ? Staff educated on keeping chemicals secure. ? Housekeeping cart checked immediately but was not broken. Housekeeper educated on how to lock cart properly. ? Maintenance office secured immediately. ? Chemicals will be properly secured in the kitchen, maintenance, and laundry rooms at all times. Staff and families will be educated on proper storage of chemicals. ? Random observations will be made to ensure that chemicals are properly secured. All resident rooms will be monitored randomly each month to ensure that chemicals are properly stored. ? Dietary supervisor, maintenance director, and Housekeeping supervisor or designees will monitor the kitchen, offices and laundry rooms. Unit Coordinator or Designee will audit resident rooms.

Standard #: 22VAC40-72-850-C
Description: Based on a tour of the physical plant to ensure correction of standards cited on the last monitoring inspection, it was observed that the facility failed to keep the building well-ventilated and free from foul, stale and musty odors. Evidence: Room 301 contained a very strong urine odor when inspected on 1/24/2013 and houses two residents.

Action to be Taken: . Room cleaned and is odor free. ? Trash to be picked up twice a shift by staff. ? Room will be checked daily and as needed for odors. ? Residents instructed to tie bags of trash up when disposing of incontinence products. ? Laundry will be monitored for smells.

Standard #: 22VAC40-72-930-C
Description: Based on review of facility documentation and discussion with staff on duty during the inspection, the facility has failed to implement a quarterly review on the emergency preparedness and response plan for all staff, residents and volunteers. Evidence: The facility provided documentation of seventeen employees attending a review on emergency preparedness on 7/16/2012 and with the nursing department on 10/24/2012. The facility has conducted an emergency review with residents who attended a Resident Council meeting, a community meeting that included invitation to families and legal representatives and at ISP review time. The facility has not implemented a quarterly review ( every three months) with all staff and all residents. The assisted living facility has 56 employees. The date given by the facility to ensure that reviews of the emergency preparedness and response plan were conducted with all staff and all residents when cited on the 5/17/2012 inspection was 6/20/2012, which would have made reviews required by 9/20/2012 and 12/20/2012.

Action to be Taken: ? A review of the emergency preparedness and response plan will be conducted with all residents who do not attend the quarterly resident meeting one-on-one, via newsletter and prior to the start of a major celebration for each quarter. ? Written documentation will be maintained for all residents who participated in the review of the emergency preparedness plan to ensure that all residents have received/reviewed the information. ? Random audits of records will be completed to ensure that all residents have reviewed the emergency preparedness plan. ? The Maintenance and Activity Directors, and Administrator or designee will complete the corrective actions.

Standard #: 22VAC40-72-970-B
Description: Based on review of facility documentation and discussion with staff on duty during the inspection, the facility has failed to have all staff on each shift participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: The facility has documentation of an "elopement drill" on 8/3/2012 with five members of the nursing department; on 8/8/2012 with seven members of the nursing department. On 8/15/20 the facility has documentation of an elopement, medical emergency and access of medical information and supplies with the nursing department. The assisted living facility has a total of 56 employees. The date of correction given by the facility when cited for this non-compliance on 5/17/2012 was 6/20/2012, which would have also made a resident emergency practice due by 12/20/2012. The facility has failed to have all staff employed in the assisted living facility participate in the exercises and lacks documentation of a mental health emergency, notification to families or legal representatives and the regional licensing department.

Action to be Taken: ? Will use the template given to facility at time of inspection to ensure all areas of regulation are covered and will educate staff using this template. ? Documentation of the elopement exercise completed will be maintained in the appropriate binder. ? An exercise which addresses all six elements will be practiced on each shift. Written documentation of all exercises will be completed and maintained for 2 years. ? Records will be audited every six months to ensure that proper documentation is recorded. ? The DON, Administrator or designee will ensure that the exercise is completed.

Disclaimer:
A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.