VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Jan. 31, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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 SANCTIONS.

Technical Assistance:

320-A

Comments:

The LI for Our Lady of the Valley conducted an unannounced renewal study at the facility on 1/31/2020 from 8:30am until 2:30pm in conjunction with two additional LIs and noted 89 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the facility physical plant was conducted and the morning medication pass and mid day meal were observed. Previous violations were reviewed. Please respond back to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-5982.

Violations:

Standard #:	22VAC40-73-310-B
Description:	310-B Based on review of resident records, the facility failed to ensure that all required information for the determination of admitting a resident to the facility was obtained. EVIDENCE: 1. The records for resident 2, admitted on 1/25/2020, and resident 5, admitted on 12/17/2019, did not contain notation of a documented interview being conducted with the resident prior to admission.
Plan of Correction:	1. THE DOCUMENTED INTERVIEW FOR RESIDENT #2 WAS COMPLETED ON 1/25/2020, THE SAME DAY OF ADMISSION. THE DOCUMENTED INTERVIEW FOR RESIDENT #5 WAS COMPLETED ON 12/16/19 AND THE RESIDENT WAS ADMITTED ON 12/17/19. 2. AN IN-SERVICE HAS BEEN COMPLETED WITH THE ADMISSIONS TEAM TO ENSURE THE RESIDENT DOCUMENTED INTERVIEW IS COMPLETED PRIOR TO ADMISSION. 3. ALL FUTURE ADMISSIONS WILL HAVE THE DOCUMENTED INTERVIEW COMPLETED PRIOR TO ADMISSION AND REVIEWED BY THE ADMINISTRATOR. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-350-B
Description:	350-B Based on resident record review, the facility failed to ensure whether the resident is a registered sex offender. EVIDENCE: 1. The record for resident 10 did not contain documentation regarding the resident?s registered sex offender inquiry and status.
Plan of Correction:	1. A SEX OFFENDER INQUIRY WAS COMPLETED ON RESIDENT #10 ON 2/24/2020. 2. ALL CURRENT RESIDENTS HAVE A SEX OFFENDER INQUIRY ON FILE. 3. THE DIRECTOR OF ADMISSIONS WILL COMPLETE A SEX OFFENDER INQUIRY ON ALL NEW RESIDENTS PRIOR TO ADMISSION AND REVIEWED BY THE ADMINISTRATOR. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-380-A
Description:	380-A Based on resident record review, the facility failed to ensure prior to or at the time of admission, the residents? personal and social information were obtained. EVIDENCE: 1. The record for resident 9 did not contain any information regarding hobbies, interests, and current behavioral and social functioning including strengths and problems. 2. The record for resident 10 did not contain any information for previous mental health/mental retardation services history, current behavioral and social functioning including strengths and problems and substance abuse history. 3. The personal and social data form in the record for resident 2 admitted on 1/25/2020, had documentation of ?N/A? under the area for the resident current behavioral and social functioning including strengths and weaknesses. 4. The personal and social data form in the record for resident 5 admitted on 12/17/2019, had documentation of ?N/A? under the area for the resident current behavioral and social functioning including strengths and weaknesses.
Plan of Correction:	1. THE PERSONAL AND SOCIAL DATA FOR RESIDENTS #9, 10, 2, AND 5 HAS BEEN UPDATED TO REFLECT CURRENT BEHAVIORAL AND SOCIAL FUNCTIONING INCLUDING STRENGTHS AND WEAKNESSES. 2. AN IN-SERVICE HAS BEEN COMPLETED WITH THE ADMISSIONS TEAM TO ENSURE THE PERSONAL AND SOCIAL DATA FORMS CONTAIN ALL DATA NECESSARY FOR RESIDENT ADMISSION INCLUDING BEHAVIORAL AND SOCIAL FUNCTIONING ALONG WITH STRENGTHS AND WEAKNESSES. 3. ALL FUTURE ADMISSIONS WILL HAVE THE PERSONAL AND SOCIAL DATA FORM REVIEWED BY THE ADMINISTRATOR. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-480-E
Description:	480-E Based on resident record review, the facility failed to ensure the residents? services provided, evaluations of progress, and other pertinent information regarding rehabilitative services were recorded in the residents? records. EVIDENCE: 1. The record for resident 9 contained an order for physical therapy but there was no documentation in the record regarding the start of physical therapy services. Staff 1 obtained physical therapy notes for resident 9 during inspection. 2. The record for resident 10 contained an order for occupational therapy and speech therapy but there was no documentation in the record regarding the start of occupational or speech therapy. Staff 1 obtained occupational and speech therapy notes for resident 10 during inspection.
Plan of Correction:	1. THE REHABILITATIVE SERVICE NOTES ARE CURRENT IN RECORDS #9 AND #10. 2. REHABILITATIVE SERVICE NOTES ARE PROVIDED DAILY TO THE DIRECTOR OF NURSING FOR REVIEW. THE DIRECTOR OF REHABILITATIVE SERVICES REVIEWS RESIDENT THERAPY NOTES WITH THE INTERDISCIPLINARY TEAM WEEKLY. 3. RESIDENT RECORDS ARE CURRENT WITH THERAPY NOTES AND THE DIRECTOR OF NURSING/DESIGNEE WILL AUDIT WEEKLY FOR COMPLIANCE. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-640-A
Description:	640-A Based on observation of the facility medication carts, the facility to implement their medication management policy in regards to methods to prevent the use of outdated or expired medications and methods to ensure accurate counts of controlled substances. EVIDENCE: 1. Lantus Insulin for resident 2 was noted to be opened in the first floor medication cart on the day of inspection. There was no date recorded as to when the insulin was opened to ensure that the medication is not administered after expiration per manufacturer?s instructions. The facility medication management policy has documentation under procedures that medications will be checked to ensure that they are not damaged, contaminated or expired prior to administering. 2. The facility controlled drug shift to shift count logs for January 2020 did not have shift signatures for the on-going staff person on 3 to 11 on 1/25 and 1/26/2020 on the first floor cart, the off going staff person on 7 to 3 on 1/24/2020 on the second floor cart and for the off going staff person on 3 to 11 on 1/7/2020 on the third floor cart. The facility medication management plan has documentation that at the end of each shift all controlled medications will be counted by the staff person leaving the cart and the staff person taking the cart. Both staff persons will acknowledge that they have counted the controlled drugs on hand and have found the count to be correct with the quantity stated on the controlled drug count record.
Plan of Correction:	1.) 1. THE LANTUS INSULIN FOR RESIDENT #2 WAS REPLACED AND DATED ON THE DATE OF INSPECTION. 2. THE DIRECTOR OF NURSING COMPLETED AN AUDIT OF ALL MEDICATION CARTS TO ENSURE INSULIN WAS DATED PER THE MEDICATION MANAGEMENT PLAN. 3. THE DIRECTOR OF NURSING/DESIGNEE WILL AUDIT ALL MEDICATION CARTS WEEKLY TO ENSURE ALL MEDICATIONS ARE DATED APPROPRIATELY PER THE MEDICATION MANAGEMENT PLAN. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE. 2.) 1. THE CONTROLLED DRUG SHIFT TO SHIFT COUNT LOGS FOR JANUARY 2020 HAVE BEEN UPDATED WITH THE CORRECT STAFF SIGNATURES. 2. THE DIRECTOR OF NURSING COMPLETED AN AUDIT OF ALL JANUARY CONTROLLED DRUG LOGS TO ENSURE COMPLIANCE. 3. THE DIRECTOR OF NURSING/DESIGNEE WILL AUDIT THE CONTROLLED DRUG LOGS WEEKLY. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-660-A-6
Description:	660-A Based on observations made of the facility medication carts, the facility failed to follow pharmacy instructions in regards to the refrigeration of medications. EVIDENCE: 1. An unopened bottle of Latanoprost 0.0005% eye drops was observed in the medication cart for resident 11. Pharmacy instructions on the box indicate to refrigerate this medication until opening.
Plan of Correction:	1. THE LATANOPROST EYE DROPS WERE DELIVERED THE DATE OF INSPECTION AND WITHIN THE REFRIGERATION WINDOW. THE MEDICATION WAS PLACED IN THE REFRIGERATOR ON THE DATE OF INSPECTION. 2. AN IN-SERVICE WAS COMPLETED WITH ALL LICENSED MEDICATION STAFF REGARDING REFRIGERATED MEDICATIONS AND STORAGE INSTRUCTIONS. 3. THE DIRECTOR OF NURSING/DESIGNEE WILL CHECK PHARMACY DELIVERIES DAILY TO ENSURE MEDICATIONS ARE STORED PER PHARMACY RECOMMENDATIONS. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-670-1
Description:	670-1 Based on record review, the facility failed to ensure that staff who administer medications are licensed by the Commonwealth of Virginia. EVIDENCE: The record for staff 3 indicated that the certification for the registered medication aide on-duty expired 11/30/2019. Further review of the Department of Health Professions website verified the expired certification.
Plan of Correction:	1. STAFF #3 IS LICENSED BY THE COMMONWEALTH OF VIRGINIA. THE LICENSE WAS RENEWED ON THE DATE OF INSPECTION 1/31/2020. 2. ALL LICENSED EMPLOYEE FILES WERE AUDITED TO INSPECT LICENSE EXPIRATION DATES. 3. THE BUSINESS OFFICE MANAGER/DESIGNEE WILL HAVE A SPREADSHEET TO TRACK LICENSE EXPIRATION DATES, ADDING NEW EMPLOYEES UPON HIRE. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-680-B
Description:	680-B Based on observations of the facility medication carts, the facility failed to ensure that all medications remained in the pharmacy issued container with prescription label attached until administered to the resident. EVIDENCE: 1. The first floor medication cart was noted to contain one gray, one yellow and one white pill lying loose in the bottom of the drawers. 2. The third floor medication carts was noted to contain one ? white pill, one ? orange pill and one white pill lying loose in the bottom of the drawers.
Plan of Correction:	1. THE LOOSE PILLS WERE REMOVED FROM CART 1 AND CART 2 ON THE DAY OF INSPECTION. 2. ALL MEDICATION CARTS WERE CLEANED THOROUGHLY TO ENSURE NO ADDITIONAL LOOSE PILLS WERE FOUND. THE MEDICATION CARTS WILL BE REORGANIZED FOR MORE EFFICIENT STORAGE. 3. THE DIRECTOR NURSING/DESIGNEE WILL AUDIT THE MEDICATION CARTS WEEKLY TO ENSURE NO LOOSE PILLS ARE IN THE MEDICATION CARTS. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-860-D
Description:	860-D Based on observation, the facility failed to ensure that any operable window shall be effectively screened. EVIDENCE: Each of the three floors of the facility contained operable windows at the end of the hallway; however, there was no screen on any of the five windows observed.
Plan of Correction:	1. THE WINDOWS AT THE END OF EACH HALLWAY ARE SECURE AND SCREENS HAVE BEEN PLACED IN ADDITION TO THE BOLTS ALLOWING THE WINDOW TO OPEN ONLY SEVERAL INCHES. 2. ALL WINDOWS IN THE BUILDING ARE SECURE AND WILL BE INSPECTED FOR SCREEN PLACEMENT. SCREENS WILL BE PLACED IN ALL REMAINING WINDOWS AS NEEDED. 3. THE DIRECTOR OF MAINTENANCE OR DESIGNEE WILL INSPECT WINDOWS MONTHLY FOR SCREEN PLACEMENT AND SECURITY. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.
Standard #:	22VAC40-73-870-B
Description:	870-B Based on observation, the facility failed to ensure that the building was free of any foul odors. EVIDENCE: While conducting the physical tour of the facility, an odor of urine was apparent in a hallway on the 2nd floor of the facility.
Plan of Correction:	1. THE SOURCE OF ODOR WAS REMOVED FROM THE FACILITY ON THE DATE OF INSPECTION, 1/31/2020. 2. ADDITIONAL HOUSEKEEPING SERVICES ARE IN PLACE TO ENSURE ALL FLOORS ARE FREE OF ODOR. 3. A DAILY COMMUNITY WALK-THROUGH WILL BE COMPLETED BY THE HOUSEKEEPING SUPERVISOR TO ENSURE THE BUILDING IS FREE OF ODOR. 4. THE ADMINISTRATOR/DESIGNEE WILL ENSURE COMPLIANCE.