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: June 21, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/21/2022 12:00 PM ? 1:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 5/15/2022 regarding allegations in the area(s) of: Resident elopement from the secure unit. Number of residents present at the facility at the beginning of the inspection: 90 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1150-A
Description:	Based on staff interview and resident record review, the facility failed to ensure that doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, constant staff oversight, and locking devices. EVIDENCE: 1. With regard to resident 1 exiting the secure unit, a written statement of events by staff 2 states, ?Upon review of the video camera system, I witnessed local EMS open the entrance/exit door of the memory care unit with the assistance of a staff member to unlock the door. Upon opening the door, the door attached to the magnetic device in order to move the stretcher out of the unit. When the staff member walked toward the door to open EMS, she paused and then turned away from the door to walk back toward the nurses station. Forty four seconds later, resident 1 walked out of the unit. The staff member was then alerted that the door was open by a family member who was walking toward the door. The staff member then walked toward the door to close it. The door was open for approximately one minute and 34 seconds before being closed. Per the video, it cannot be determined if the alarm was sounding as the video system does not have audio. According to the statement from the staff member, it was not?. 2. A review of the detailed census report for the secure unit (Christopher Center) indicates that there were 22 residents in the secure unit on 05/15/2022 at the time the incident occurred. The secure unit (Christopher Center) schedule and assignment sheet from 05/15/2022 indicates that staff 3, 4, and 5 were on duty in the secure unit at the time of resident 1 exit. 3. Staff 2 written statement indicates that based on statements received by the three staff members regarding the event, ?two staff members were assisting other residents in the dining room, and the third staff member was collecting appropriate information for the resident requiring EMS services?. In addition, staff 6 written statement states, ?On 05/15/2022 I was driving on Gainsboro Rd towards work when I saw someone who looks like a resident from Memory Care. I wasn?t that sure so I went and parked my car on Jefferson Ave and walked back to Gainsboro Rd and that when I realize that it was resident 1. I held her hand and walked her back to the facility and took her back to Memory Care?.
Plan of Correction:	1. All memory care and AL staff were reeducated on supervision of memory care exit/entrance in the event of an emergency alarm, fire drill, or EMS arrival/departure. 2. In the event of an emergency alarm, or need for emergency exit/entrance onto the Memory Care Unit, ALL staff members will report immediately to all entrances/exits to secure the environment for wandering and exit seeking residents. 3. The DON or designee will conduct an elopement drill weekly for one month, then two times per month and monthly thereafter on rotating shifts to ensure staff are prepared for any elopement or emergency scenario where unit security could be compromised. Maintenance will check door alarm monthly to ensure it is working properly. 4. The Administrator/Designee will monitor and provide oversight for compliance with staff education and training as well as reviewed in the quarterly QA with minutes recorded and reviewed.
Standard #:	22VAC40-73-460-D
Description:	Based on staff interview and resident record review, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. EVIDENCE: 1. Resident 1 moved in to the facility?s memory care unit on 11/17/2021. 2. The form PHYSICAL ASSESSMENT OF SERIOUS COGNITIVE IMPAIRMENT FOR ADMISSION TO MEMORY CARE CENTER for resident 1, dated 10/11/2021, indicated that resident 1 has the diagnostic impressions of ?Early onset Alzheimer?s disease/Dementia with behaviors?. The form indicated that resident 1 displays ?Compulsive behaviors of pacing and wandering?. Further, the form verified that resident 1 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and has the inability to recognize danger or protect her own safety and welfare. 3. The individualized service plan (ISP) for resident 1, dated 11/17/2021, identifies that ?Resident is exit seeking?, which has an identified date of 5/12/2022. The services provided by the facility for this identified need state ?Resident will seek to exit unit when doors are opened. All staff and visitors will not prop open doors or hold doors open. In the event a door must be opened for any period of time, staff will stay at the door to ensure that all residents remain on unit?. 4. Staff 1 submitted an initial facility incident report to Licensing Inspector, dated 05/16/2022, which was supplemented by a final incident report on 05/20/2022. The final report states ?On the afternoon of Sunday, May 15, 2022, at 12:39 PM, resident 1 exited the memory care unit. She entered the elevator, where she exited on the 2nd floor, walked out the front door and walked up North Jefferson Street?She was then picked up by a staff member who was reporting to work at 1:25 PM. Resident 1 returned without injury?. The report further states ?Per video camera system, this event occurred when local EMS had responded to a call and transport for another Memory care resident. Upon opening the door to the unit to exit, EMS staff opened the door which attached to a magnetic device therefore propping the door open. Directly after EMS exited the unit, resident 1 entered into the area and walked out the door. She entered the elevator with the EMS staff and followed them out the door. Staff began an internal search of all assisted living staff trying to find the resident. Further, maintenance staff were alerted in order to review the camera system trying to find her location?. 5. In-person interview with staff 1 and staff 2 on 06/21/2022 confirmed the details of the report and clarified that resident 1 was located by the incoming staff member around the intersection of Celtic Way NW and Gainsboro Road NW, in the direction of Orange Avenue. 6. According to online data from Weather Underground, the actual high temperature for 05/15/2022 was 82 degrees Fahrenheit and precipitation was 0.03 inches. 7. According to Google Maps, the distance from 650 N. Jefferson St, Roanoke, VA 24016 (Our Lady of the Valley) to Celtic Way NW, Roanoke, VA is approximately a 4 min (0.2 mile) walk via N Jefferson St.
Plan of Correction:	1. All memory care and AL staff were reeducated on supervision of residents with specialized needs with regards to wandering and exit seeking resident. Photos of all residents in memory care with a potential exit seeking behavior was updated and placed in folder at main Assisted Living Reception desk. 2. Direct care staff will respond immediately to door security alarms and complete a resident census count for the Memory Care unit. Upon EMS arrival and departure from the unit, 1 staff member will report to the main entrance/exit of the unit to monitor the door. 3. The DON or designee will conduct an elopement drill weekly for one month, then two times per month and monthly thereafter on rotating shifts to ensure staff are prepared for any elopement or emergency scenario where unit security could be compromised. Maintenance will check door alarm monthly to ensure it is working properly. 4. The Administrator/Designee will monitor and provide oversight for staff education and training as well as reviewed in the quarterly QA with minutes recorded and reviewed.