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: Feb. 21, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/21/2023 from 08:50 AM until 05:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-100-C-2
Description:	Based on an audit of medication carts and document review, the facility failed to implement a portion of its infection control policy regarding blood glucose monitoring practices that are consistent with CDC recommendations. EVIDENCE: 1. The document ?Blood Glucose Monitoring? provided during on-site inspection on 02/21/2023 contained the following documentation regarding the facility's blood glucose monitoring practices: ?It is the policy of the facility to monitor blood glucose levels as ordered by the physician using proper procedures as recommended by CDC to prevent the transmission of bloodborne pathogens? and ?The meter will be labeled for the specific resident and stored in a bag labeled with the resident?s name.? 2. The blood glucose meters for resident 11 and resident 12 located in the 301-320 medication cart did not contain the name of the residents on the meter.
Plan of Correction:	1. Residents #11 and #12's, blood glucose meters are now identified with the residents' name. 2. Audit of resident's blood glucose meters was completed by the DON/designee, to ensure compliance with proper identification of resident's name on the meter. 3. RMAs were re-educated that a resident's blood glucose meter must have the residents name on it. Blood glucose meters will be audited monthly, for 3 months, by DON/designee, to ensure residents names are in place on the meter. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-210-D
Description:	Based on staff record review and staff interview, the facility failed to ensure that in addition to the 18 hours of required annual training for direct care staff, that the required annual continuing education for medication aides was also completed. EVIDENCE: 1. The Virginia Board of Nursing?s Regulations Governing the Registration of Medication Aides, effective 02/06/2020, list that the continuing education required for registered medication aides shall consist of four hours of population-specific training in medication administration in the assisted living facility in which the aide is employed or a refresher course in medication administration offered by an approved program. 2. The record for staff 1 indicated that staff 1 is a registered medication aide, with a hire date of 08/25/2000; however, the record did not contain documentation that this staff member had taken four hours of population-specific training in medication administration or an annual medication administration refresher course in 2022. 3. The record for staff 3 indicated that staff 3 is a registered medication aide, with a hire date of 07/23/2018; however, the record did not contain documentation that this staff member had taken four hours of population-specific training in medication administration or an annual medication administration refresher course in 2022. 4. Interview with staff 6 and staff 7 confirmed that annual medication refresher training has not occurred for staff 1 and staff 3.
Plan of Correction:	1. Staff #1 and #3 received their annual four-hour refresher medication administration course. 2. Audit was completed of RMA's employee files to determine compliance with the medication administration course and scheduled as needed. 3. RMA's were re-educated that annual education is required to maintain medication administration certification. BOM/designee will audit RMAs employee's files monthly, for 3 months, then annually thereafter to ensure annual training completed. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-250-D
Description:	250-D.1.a. Based on staff record review and staff interview, the facility failed to ensure a staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB). EVIDENCE: 1. The record for staff 4, date of hire 04/05/2022, contained documentation that a PPD skin test had been placed on staff 4 on 04/05/2022; however, the documentation did not include information that the PPD skin test had been read. 2. Interview with staff 6 confirmed this was accurate. 250-D.2.c Based on staff record review and staff interview, the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. The record for staff 1 contained a TB screening form dated 05/25/2021. 2. The record for staff 3 contained a TB screening form dated 05/06/2021. 3. Interview with staff 6 and staff 7 confirmed that documentation of a more recent TB assessment for staff 1 and staff 3 does not exist.
Plan of Correction:	250-D.1.a 1. Staff #4 does not work in the AL. 2. Audit of new employee files was completed by the BOM/designee to ensure PPD skin tests were completed and read. PPD's were administrated and read as needed. 3. Talent Director/designee will ensure new hires PPDs skin tests are placed and read. BOM/designee will review new hire employee packets monthly, for 3 months, and annually thereafter, to ensure compliance. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting. 250-D.2.c 1. PPD screenings for staff #1 and #3 were completed. 2. Audit of employee files was completed by BOM/designee to ensure annual TB screening was completed. Screenings completed as needed. 3. BOM/designee will audit employee files monthly, for 3 months, and annually, thereafter for compliance. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-270-1
Description:	Based on resident record review, staff record review, and staff interview, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents, and that the training includes, at a minimum, information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior. EVIDENCE: 1. Facility documentation indicates aggressive behaviors presented by resident 8 on 01/25/2023, 01/28/2023, and 01/31/2023. 2. The record for staff 2, hired 03/08/2022, did not contain documentation of having aggressive behavior training prior to being involved in the care of such residents. 3. This LI observed staff 2 providing direct care services and medication administration in the facility?s memory care unit on the date of inspection. 4. The record for staff 4, date of hire 04/05/2022, did not include documentation that staff 4 had training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. 5. Interview with staff 6 confirmed that no aggressive behavior training documentation exists for staff 2 and staff 4.
Plan of Correction:	1. Staff# 2 and #4 received training on methods for dealing with residents who have a history of aggressive behaviors or of dangerously agitated states. 2. Audit of MC staff employee files was completed by BOM/designee to ensure evidence of education on aggressive behavior training was completed prior to being involved with residents having aggressive behaviors. Education completed as needed. 3. Aggressive behavior training will be added to new employee orientation. BOM/designee will review new hire packets monthly, for 3 months, and annually thereafter, to ensure aggressive behavior training occurred prior to being involved in the care of residents with aggressive behaviors. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-270-4
Description:	Based on resident record review, staff record review, and staff interview, the facility failed to ensure direct care staff had a refresher training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states and that the training includes, at a minimum, information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior. EVIDENCE: 1. Facility documentation indicates aggressive behaviors presented by resident 8 on 01/25/2023, 01/28/2023, and 01/31/2023. 2. The record for staff 1, date of hire 08/25/2000, did not contain documentation of having an annual aggressive behavior refresher training during the most recent annual training period of 08/25/2021 through 08/24/2022. 3. The record for staff 3, date of hire 07/23/2018, did not contain documentation of having an annual aggressive behavior refresher training during the most recent annual training period of 07/23/2021 through 07/22/2022. 4. Interview with staff 6 confirmed that there is no documented aggressive behavior refresher training documentation exists for staff 1 and staff 3 during their most recent annual training period.
Plan of Correction:	1. Staff # 1 and #3 received training on methods for dealing with residents who have a history of aggressive behaviors or of dangerously agitated states. 2. Audit of MC staff employee files was completed by BOM/designee to ensure evidence of annual aggressive behavior refresher training was completed. Education completed as needed. 3. Annual training will include aggressive behavior refresher training that includes demonstration and practical experience in self-protection and in the prevention and de- escalation of aggressive behavior. BOM/designee will audit employee files, monthly, for 3 months, and annually thereafter, to ensure annual refresher training occurred. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that for private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument (UAI) is completed as required, including updating the UAI whenever there is a significant change in the in the individual?s condition. EVIDENCE: The UAI for resident 8, dated 12/06/2022, states that the resident displays appropriate behaviors; however, facility progress notes document aggressive behaviors toward staff and other residents by resident 8 on 01/25/2023, 01/28/2023, and 01/31/2023.
Plan of Correction:	1. Resident #S's UAI was updated to reflect aggressive behaviors toward staff and other residents 2. An audit of UAls was completed to ensure residents aggressive behaviors have been documented. Updates completed as needed. 3. MC nursing staff re- educated to report any aggressive behaviors to the charge nurse for UAI updates. DON/designee will audit UAls monthly, for 3 months, to ensure aggressive behaviors have been documented. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) were completed as required. EVIDENCE: 1. The ISP for resident 2, dated 09/27/2022, indicates that the resident is receiving physical and occupational therapy. 2. Interview with staff 8 revealed that the resident is not currently receiving physical and occupational therapy. 3. The ISP for resident 9, dated 09/09/2022, indicates that the resident wears TED hose and that staff are to place the TED hose on the resident in the morning and remove in the evening; however, the record for resident 9 contains a physician?s order, dated 12/08/2022, to discontinue TED hose. 4. Interview with staff 6 confirmed the order is accurate and that the resident no longer wears TED hose.
Plan of Correction:	1. Residents #2 and #9 ISP's were updated to discontinue therapy orders and TED hose. 2. Audit of ISPs was completed, by DON/designee to confirm all discontinued services were removed. Corrections made as needed. 3. DON/Unit coordinator re-educated regarding accuracy of ISP's and removing discontinued services. DON/designee will audit ISP's monthly, for 3 months, to ensure accuracy of services are documented. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. EVIDENCE: 1. The ISP for resident 1, dated 11/02/2022, was not signed by either the licensee, administrator, or his designee, nor by the resident or the legal representative for resident 1. 2. The ISP for resident 7, updated 01/17/2023, was not signed and dated by the resident or the resident?s legal representative. 3. The ISP for resident 9, dated 09/09/2022, was not signed and dated by the licensee, administrator (or his designee) and the resident or the resident?s legal representative.
Plan of Correction:	1. Residents #1 and #9's ISP's were signed and dated by the Administrator and legal representative. Resident # 7's ISP was signed and dated by the resident. 2. Audit of ISP's was completed to ensure signature and date of the administrator and resident or legal representative was in place. Updates completed as needed. 3. Executive Director reeducated the Unit Coordinator and DON that the ISPs shall be signed and dated by the Administrator and resident or his legal representative. DON/designee will audit ISPs for required signatures, monthly, for 3 months to ensure compliance. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-480-E
Description:	Based on resident record review and staff interview, the facility failed to ensure the physician?s or other prescriber?s orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services were recorded in the resident?s record. EVIDENCE: 1. During on-site inspection on 02/21/2023, the licensing inspectors (LIs) were informed that residents 7 and 9 receive skilled nursing from an outside home health agency for wound care. 2. Documentation provided by the facility indicates that resident 7 started receiving wound care services on 02/07/2023 and resident 9 started receiving wound care services on 12/27/2022; however, the record for resident 7 only contained notes from the 01/03/2023 visit from the home health agency and the record for resident 9 did not contain any documentation from the home health agency regarding services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services that have been provided to residents 7 and 9. 3. Interview with staff 6 confirmed this was accurate and contacted the home health agency on day of inspection to have the required documentation faxed to the facility for both residents 7 and 9.
Plan of Correction:	1. Wound notes were received from the home health agency for residents # 7 and #9. 2. Audit was completed for residents receiving home health wound services to ensure current documentation is in place. Additional information obtained as needed. 3. DON/designee will audit resident records receiving home health wound service, monthly for 3 months, to ensure current documentation is in place. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-560-E
Description:	Based on observation, the facility failed to ensure that all resident records are kept in a locked area. EVIDENCE: While performing a physical plant tour of the memory care unit on the date of inspection, LI observed a rolling cart behind the nurses? station which was open and unlocked and contained resident records.
Plan of Correction:	1. MC residents records are now secured in a locked office behind the nurses station. 2. MC resident records wilt be kept in a locked area and checked on daily rounds. 3. MC nursing team re-educated that resident records are kept in a locked area. The DON/designee will conduct weekly rounds, for 1 month, monthly rounds for 3 months, documenting medical records are in a locked area. 4i Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings wilt be reported to the quality assurance meeting.
Standard #:	22VAC40-73-640-A
Description:	Based on observation during medication cart audits and document review, the facility failed to implement a portion of its medication management policy regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management policy, revised 08/14/2019, provided during on-site inspection on 02/21/2023 contained the following documentation regarding accurate counts of all controlled substances: ?At the end of each shift, the controlled medication 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 drug on hand and have found that the quantity of each controlled medication counted is in agreement with the quantity stated on the Controlled Drug Count Record.? 2. At approximately 9:08AM, collateral 1 noted that the controlled drug shift to shift count log for the 217-234 medication cart did not contain the signature of staff 3 as the on-coming medication staff for 02/21/2023 at 7:00AM. Staff 3 acknowledged that she did perform the count; however, she did not sign the log. 3. The controlled drug shift to shift count log for the 301-320 medication cart was noted to have three instances where the log was not signed either by the off-going or by the on-coming medication staff and the 321-340 medication cart was noted to have one instance where the log was noted signed by the off-going medication staff.
Plan of Correction:	1. Staff member #3 received corrective counseling and education on the policy for counting controlled substances whenever assigned medication administration staff changes. 2. Controlled substance narcotic sheets were audited, by DON/designee, for missing signatures identifying noncompliance of staff. Correction actions occurred as needed. 3. RMAs re-educated on the medication policy regarding counting of controlled substances whenever assigned medication administration staff changes. The DON/designee will audit controlled narcotic sheets weekly for 1 month, and monthly for 3 months, for signatures indicating accurate counting of narcotic at each shift change. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, resident record review, resident interview, and staff interview, the facility failed to ensure that a resident is only permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication. EVIDENCE: 1. The UAI for resident 2, dated 09/19/2022, indicates that the resident requires medications to be administered/monitored by a registered medication aide, a licensed practical nurse, or a registered nurse. 2. During the on-site inspection, collateral 1 and staff 3 noted that there was an Albuterol Sulfate inhaler on the table beside the resident?s recliner. 3. Resident 2 informed collateral 1 and staff 3 that she has been using the inhaler due to shortness of breath and wheezing. 4. Collateral 1 and staff 3 noted that the inhaler contained an expiration date of 09/2022. 5. The record for resident 2 did not contain a physician?s order that the resident can keep at bedside and self-administer Albuterol Sulfate. 6. Interview with staff 6 confirmed this was accurate.
Plan of Correction:	1. Albuterol Sulfate was removed from residents #2's room. 2. Room inspections completed to ensure no beds are at bedside and residents with medication in apartments have a self-med assessment and physician order in place. 3. Nursing staff/housekeeping/management reeducated that no medication can be left at bedside. Residents with their own medications must be in an out-of-sight place in the room and resident must have a self-med assessment, physician order and ensure medication has not expired. Nursing staff will assess areas daily when providing resident care. DON/designee will inspect apartments monthly, for 3 months, to ensure compliance and document findings. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-680-K
Description:	Based on resident record review, the facility failed to ensure that the use of PRN (as-needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed; licensed health care professionals administer PRN medication; or if medication aides administer PRN medication, the resident?s physician or other prescriber?s order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. Collateral 1 observed a bottle of PRN Naxolone HCL 4MG spray for resident 13 in the medication cart. 2. The record for resident 13 contained a physician?s order for Naloxone HCL 4MG spray which states to spray 0.1 milliliter in one nostril by intranasal route nasal every 2-3 minutes as needed, alternating nostrils with each dose; however, that order does not include the symptoms that indicate the need for the use of the medication, the exact time frames the medication is to be given in a 24-hour period, nor does it include directions as to what to do if symptoms persist. 3. Per a review of the staff roster and through observation, the facility does employ registered medication aides to regularly administer medications to residents.
Plan of Correction:	1. Naxolone HCL 4 mg spray was removed from the medication cart for resident #13 and order discontinued due to non use. 2. Audit completed of medication carts to ensure no Naxolone HCL sprays are present. 3. Nursing staff administrating medications were re-educated that all prn orders shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24 hour period and directions as to what to do if symptoms persist. DON/designee will review pm orders, weekly for 1 month, and monthly for 3 months, to ensure compliance with physician order. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-860-D
Description:	Based on observation, the facility failed to ensure that any operable window shall be effectively screened. EVIDENCE: While performing a physical plant tour of the facility on the date of inspection, LI observed that the windows in rooms 7 and 14 had the ability to open; however, neither window had a screen.
Plan of Correction:	1. Screens were placed in the windows in rooms 7 and 14 2. Operable windows in the AL and MC were inspected to identify additional window screens needed by the Director of Maintenance/designee and ordered/replaced as needed A. Residents and employees re-educated that operable windows need a screen and to report missing screens immediately to the maintenance department. B. Maintenance/designee will inspect windows for screens during room inspections, every month for 3 months. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All findings will be reported to the quality assurance meeting.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. It was noted by collateral 1 that the door to room 128 was unlocked and a spray can of HDX disinfectant spray was located in the bathroom. 2. Also, collateral 1 noted that the door to room 127 was unlocked and the room contained the following items: a spray can of Zinsser stain sealing ceiling paint, a container of 30 seconds outdoor cleaner concentrate and a container of Simple Green all-purpose cleaner, and multiple gallons of paint.
Plan of Correction:	1. Rooms 127 and 128 doors are now locked when not occupied. 2. Maintenance/designee will audit rooms under renovation/construction to ensure a proper locking device is in place. Corrections made as needed. 3. Maintenance staff were re-educated to ensure all rooms under construction/renovation are locked. Apartments unoccupied due to renovation/construction will be inspected by maintenance/ designee, during daily rounds to ensure locked when unoccupied. 4. Administrator/designee will conduct random monthly audits to ensure compliance. All audit findings will be reported to the quality assurance meeting.