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: April 12, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

440-A, 640-A, 860-I, 870-A

Comments:

The LI for Our Lady of the Valley, along with an additional LI, conducted an unannounced renewal study on 04/12/2022 from 9:00 AM until 5:00 PM, finding 90 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, a review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and craft activity. Ten resident records were thoroughly reviewed, and an additional three were partially reviewed in relation to the observation of the medication pass, special diets, or services received. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of five staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the facility Administrator and Directors of Nursing on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	1090-A Based on record review, the facility failed to ensure that prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist or by an independent physician as having a serious cognitive impairment due to a primary diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: The form ?Physician Assessment of Serious Cognitive Impairment for Admission to Memory Care Center? for resident 3, completed on 03/31/2022, was marked ?No? for the question ?Does the individual named above have an inability to recognize danger or protect his/her own safety and welfare??.
Plan of Correction:	1. Assessment of Serious Cognitive Impairment for resident 3 was resent to physician for correction and was returned on 04/15/2022. 2. An audit was conducted on all current residents and any Serious Cognitive Impairment forms were sent to physician for correction. All were returned on 04/15/2022. 3. All potential resident Serious Cognitive Impairment forms will be reviewed for accuracy prior to admission by the Admissions Director and Director of Nursing. Any form that is not accurate will be reviewed with physician to ensure that resident is appropriate for Memory Care Center prior to admission. 4. The Administrator/designee will complete monthly audits of newly admitted residents to ensure compliance.
Standard #:	22VAC40-73-1130-C
Description:	1130-C Based on documentation review, the facility failed to ensure that during night hours, when 22 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit. EVIDENCE: 1. Interview with staff 6 indicated that the facility?s special care unit housed 18 residents on the date of inspection. 2. When reviewing the facility?s staff assignment sheets for the two weeks prior to the date of inspection, LI observed that on 04/03/2022 and 04/09/2022 on the 10:45 PM to 7:15 AM shift, only one direct care staff member was listed as having worked in the special care unit. 3. Interview with staff 7 indicated that the facility could not verify that at least two direct care staff member worked on those dates and shifts.
Plan of Correction:	1. The monthly schedule was reviewed to ensure that all night shift hours have at least two staff members on duty each night and all other shifts were staff appropriately. 2. When reviewing the daily schedule Director of nursing/designee will ensure that there is adequate staff scheduled in the secured unit to meet required minimum number of staff on all shifts. In the event of an unexpected staff absence, the nurse on call will staff appropriately. 3. Director of Nursing/designee will monitor staff requirements daily and ensure that each unit is appropriately staffed to ensure compliance. 4. The Administrator/designee will complete monthly audits to ensure compliance.
Standard #:	22VAC40-73-1150-B
Description:	1150-B Based on observation, the facility failed to have a protective device on a window in the special care unit that prevented the window from opening wide enough for a resident to crawl through. EVIDENCE: 1. During the physical plant tour on the date of inspection, collateral 1 observed that a window in the Activities Solarium in the special care unit was able to be opened wide enough for a resident to crawl through.
Plan of Correction:	1. The window in the MC activities solarium was immediately secured so it would not open wide enough for a resident to crawl through. 2. Maintenance Director/designee will inspect all memory care windows for proper securement of how far windows open. 3. Maintenance Director/designee will complete monthly inspection times 3 months of all windows on the secured unit for proper security. 4. The Administrator/designee will complete monthly inspections to ensure compliance.
Standard #:	22VAC40-73-260-A
Description:	260-A Based on record review, the facility failed to ensure that each direct care staff member shall maintain current certification in adult first aid, and each direct care staff member who does not have current certification shall receive certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff 1, hired 03/11/2002, contained certification of Adult CPR/AED/Basic First Aid training which expired 09/2021. 2. The record for staff 2, hired 08/25/2000, contained certification of Basic Life Support training which expired 08/2019. 3. The record for staff 5, hired 11/22/2021, did not contain documentation of having completed any adult first aid training. 4. Interview with staff 6 determined that these staff members did not have current certification in adult first aid.
Plan of Correction:	1. Staff members 1, 2, and 5 will obtain CPR/First Aid at next class, May 11, 2022. CPR/First Aid Classes will be scheduled monthly to ensure compliance for all current and new employees within 60 days of hire. 2. Monthly audits will be conducted by the Business Office Manager to ensure compliance of current first aid and CPR for all employees. 3. The Business office manager will audit employee files for compliance monthly times 3 months. 4. The Administrator/designee will conduct monthly audits to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on record review, the facility failed to ensure that the individualized service plan (ISP) contained all required components. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 8, dated 10/05/2021, shows that this resident needs various types of help with bathing, dressing, transferring, mobility, bowel and bladder continence, and medication administration. In addition, the individualized service plan (ISP) for resident 8, dated 10/05/2021, restates the specific needs identified from the UAI; however, the ISP does not show what services that the facility will provide to assist in meeting those needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-B
Description:	660-B Based on observation, interview, and resident record review, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication. EVIDENCE: 1. During the physical plant tour by collateral 1 on the date of inspection, resident 10 had a Primatene Mist inhaler, Vitamin D-3, and Magnesium 500 MG on the window sill next to a recliner, and two Primatene Mist inhalers on a table next to the bed. 2. Resident 10 stated that she does not have physician orders for these, and staff is not aware they are in her room. 3. The uniform assessment instrument (UAI) for resident 10, dated 04/05/2022, indicated that this resident is assessed as needing assistance to administer medications, and the resident?s individualized service plan (ISP) indicated that facility staff administers medications to resident 10. 4. The April 2022 medication administration record (MAR) for resident 10 indicated that the facility administers Vitamin D-3 25 MCG and Magnesium 400 MG daily to resident 10, and that a PRN prescription inhaler is available if needed.
Plan of Correction:	1. Medications were removed from resident room at the time of inspection. Resident will be assessed for the ability to self-medicate. If deemed safe, a physician's order will be obtained to self-administer OTC medications. If deemed unsafe, the residents OTC will be administered by the facility staff. The UAI/ISP will be updated according to physician orders. All medications that are ordered to remain in room will be kept in a secure area within the apartment. 2. A comprehensive room inspection/audit will be conducted by DON and/or designee to ensure that all residents who have medication in their apartments, have a physician's order and self-administration orders in place. All care staff and housekeeping staff members will be in serviced on completing room sweeps daily when providing resident care and/or cleaning residents apartments. 3. All apartments will be inspected by the Director of Nursing and/or designee monthly times 3 months, to ensure orders are in place for all medications and self-administration orders are up to date. Inspections will be done by the Director of Nursing and/or designee. 4. The Administrator/designee will conduct monthly audits to ensure compliance.
Standard #:	22VAC40-73-680-E
Description:	680-E Based on record review, the facility failed to ensure that medical procedures or treatments ordered by a physician shall be provided according to his instructions and documented. EVIDENCE: 1. The record for resident 9 contained a physician?s order, signed 12/09/2021, for Accu-Checks to be completed daily, which was later changed to Monday and Thursdays only; however, the medication administration record (MAR) for resident 9 did not contain documentation to support that the Accu-Checks (blood glucose monitoring) were completed on Monday 04/04/2022 and Thursday 04/07/2022.
Plan of Correction:	1. The physician's order for resident 9 stating accu-checks to be completed Monday and Thursday has been updated. The RMA/LPN will thoroughly review each resident record at the time of medication/procedure pass daily. All medications and procedures are completed timely and as ordered. 2. The Director of Nursing will re-train LPN's on proper entering of Accu-check orders in the EMAR system, review the current EMAR for Accu-check orders to ensure proper entry and processing and correct issues at the time of finding. 3. The Director of Nursing and/or designee will review EMAR records three times per week times 3 weeks, then weekly thereafter to ensure physician orders are followed and processed correctly. 4. The Administrator/designee will complete monthly audit to ensure compliance.
Standard #:	22VAC40-73-680-I
Description:	680-I Based on record review, the facility failed to ensure that the medication administration record (MAR) contained all required components. EVIDENCE: The March 2022 MAR for resident 1 did not indicate the date and time that medication was administered or attempted and initials of staff administering medication for the following medications and dates: On 03/18/2022, Levothyroxine Sodium 75 MCG tab; On 03/25/2022, Aspirin 81 MG tab, Bumetanide 0.5 MG tab, Eliqius 2.5 MG tab at 9 AM, Gabapentin 300 MG capsule, Hydralazine HCL 10 MG at 9 AM and 12 PM, Multivitamin 400 MCG tab, Simvastatin F/C 20 MG tab, Tramadol HCL F/C 50 MG tab, Vitamin D3 25 MCG tab.
Plan of Correction:	1. All med tech's/nurses will be in serviced on medication administration on 04/26/2022. RMA/LPN will be responsible for checking the EMAR system at every med pass to ensure that all medications and procedures are complete and documented as given prior to the next medication pass time. 2. Oncoming RMA/LPN/RN will review the EMAR system at shift change to ensure documentation is complete and accurate. 3. Director of Nursing/designee will audit EMAR at least three times per week times 3 weeks, then weekly thereafter to ensure accuracy, correct medication times and completion of administration at the appropriate time. Immediate re-training will be provided to individual staff members if trends are identified upon audit. 4. The Administrator/designee will complete monthly audits to ensure compliance.
Standard #:	22VAC40-73-930-D
Description:	930-D Based on document review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to other services, the facility shall document rounds that were made. EVIDENCE: 1. The facility failed to document that rounds were completed for special care unit residents 11, 12, and 13 on the following dates and times: 04/01/2022: 2 AM through 7 AM 04/03/2022: 12 AM through 7 AM 04/05/2022: 11 PM through 7 AM 04/10/2022: 6 AM and 7 AM 04/11/2022: 7AM
Plan of Correction:	1. Rounding sheet education regarding policy, procedure and fulfillment will be reviewed with all staff. 2. Oncoming staff will review round sheet at the start of shift during report to ensure rounds were documented appropriately. 3. Director of Nursing/designee will audit and review no less than weekly to ensure that rounds were complete and documented appropriately to ensure compliance. 4. Administrator/designee will complete monthly audit to ensure compliance.
Standard #:	22VAC40-73-990-C
Description:	990-C Based on record review, the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. EVIDENCE: The facility could not provide any documentation to verify that any practice exercises occurred for resident emergencies.
Plan of Correction:	1. All staff will participate in practice emergency exercise. 2. All new hires will be educated on emergency preparedness during general orientation. 3. Maintenance Director/designee will review emergency preparedness drills on quarterly basis for compliance. 4. Administrator/designee will ensure compliance.