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: Sept. 26, 2022

Complaint Related: Yes

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: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/26/2022 01:30 PM ? 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/23/2022 regarding allegations in the area(s) of: Failure to implement interventions to prevent or reduce resident falls; failing to adhere to resident requests for no medical treatment. Number of residents present at the facility at the beginning of the inspection: 90 Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Failure to implement interventions to prevent or reduce resident falls. A violation notice was issued; any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) shall be completed whenever there is a significant change in the resident?s condition. EVIDENCE: 1. The most current UAI for resident 1 at the time of inspection, dated 11/01/2021, states that resident 1 does not ambulate by wheeling; however, facility service notes indicate that resident 1 was observed in her wheelchair on 07/20/2022 at 06:30 PM; resident 1 was observed falling out of her wheelchair in the memory care sunroom on 09/15/2022 at 01:30 PM; resident 1 was observed in her wheelchair brushing her teeth at her sink just prior to being found on her back on the floor on 09/23/2022 at 06:30 AM; resident 1 was trying to get out of her wheelchair in the TV room and fell and hit her head on 10/15/2022 at 09:30 AM. 2. The most current UAI for resident 1 at the date of inspection, dated 11/01/2021, was not updated to indicate the resident?s significant change in condition which lasted longer than 30 days and required the use of a wheelchair for ambulation.
Plan of Correction:	1. The UAI and ISP was corrected for resident 1 to ensure that all services are properly noted. 2. An audit to compare UAI?s and ISP?s will be conducted to ensure accuracy as well as specifying services required for each resident on an individual basis. Any updates will be corrected immediately. 3. The Director of Nursing and/or designee will review UAI?s and ISP?s monthly for the next quarter for accuracy. 4. The Administrator/designee will complete monthly audit to ensure compliance.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on collateral interview and record review, the facility failed to ensure that the individualized service plan (ISP) included all identified needs of the resident. EVIDENCE: 1. The hospice services agreement between the facility and collateral 1, effective 02/06/2015, states that hospice shall develop a plan of care for the management and palliation of the patient?s terminal illness. In addition, the hospice services agreement states that the facility will revise its plan of care to coordinate with and be consistent with the hospice plan of care for each hospice patient. 2. The hospice plan of care, effective 05/27/2022, for resident 1 states that the resident is at risk for falls due to weakness and forgetfulness due to dementia and fall risk interventions indicate that the hospice nurse will instruct the caregiver not to leave the patient unattended and the hospice nurse will instruct the patient/caregiver/staff in safe use of wheelchair/walker. 3. Per telephone interview on 10/18/2022 at 03:30 PM, a collateral 1 representative stated that she visits the resident at least once per week and educates facility caregivers each time about the importance of not leaving resident 1 unattended due to being a high fall risk and about hospice availability 24/7. 4. The ISP for resident 1, dated 11/02/2021, indicates that resident 1 is a fall risk with the following documented dates of falls and post fall interventions: Fall on 03/09/2022, Services to be provided: Resident will have a clutter free environment and will be reminded to always keep walker in reach; Fall on 03/10/2022, Services to be provided: Resident will continue to be reminded to use call light for assistance and hourly rounds will continue; Falls on 04/22/2022, 05/18/2022, 06/20/2022, and 07/28/2022, Services to be provided: Will continue to remind resident to use walker and not ambulate without it; Fall on 09/15/2022, Services to be provided: Resident will have clutter free environment, will cue resident to use walker when observed ambulating without it/ therapy referral; Fall on 09/23/2022, Services to be provided: Resident will have a clutter free environment; will cue resident to call for assistance to stand or transfer; therapy referral. Alternately, that ISP for resident 1 was not updated to contain the fall risk intervention from the hospice plan of care that the caregiver should not leave the patient unattended, effective 05/27/2022.
Plan of Correction:	1. The Hospice care plan has been reviewed for resident 1 to ensure all services are consistent. Staff have been educated to make hourly rounds on resident due to being a fall risk. 2. An audit of hospice care plans has been conducted for review to ensure accuracy as well as specifying all services required for each resident on an individual basis. Any updates will be corrected immediately. 3. Director of Nursing and/or designee will review hospice resident care plans for accuracy on a quarterly basis ensuring accuracy and services required are noted appropriately for each resident. Care plans will be updated after any changes in condition. Care plans will be reviewed monthly for the next quarter. 4. The Administrator/designee will complete monthly audit to ensure compliance.