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. 18, 2024

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: 01/18/2024 from 08:45 AM until 04:00 PM 01/19/2024 from 08:45 AM until 11:30 AM 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 #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) contained a description of identified needs from all sources, which includes the uniform assessment instrument (UAI). EVIDENCE: 1. The UAI for resident 5, dated 11/03/2023, and the ISP for resident 5, dated 11/03/2023, both indicate that the resident requires mechanical assistance with dressing and toileting; however, the ISP does not specify what type of mechanical assistance is needed for dressing and toileting. 2. The UAI for resident 7, dated 06/14/2023, and the ISP for resident 7, dated 11/07/2023, both indicate that this resident requires mechanical assistance with toileting, transferring, and mobility; however, the ISP does not indicate what type of mechanical assistance is needed for toileting, transferring, and mobility. The same UAI and ISP for resident 7 also indicates that the resident is incontinent of bladder; however, the ISP indicates that the resident requires mechanical assistance for bladder incontinence but does not specify what type of mechanical assistance is needed. 3. The UAI for resident 8, dated 07/19/2023, indicates that this resident requires mechanical assistance and human supervision with stairclimbing and mobility; however, the ISP for resident 8, dated 07/19/2023, indicates that the resident requires mechanical assistance of handrails and staff to hold opposite hand for stairclimbing, and the resident requires mechanical assistance of a wheelchair or walker with staff physical assistance for mobility. Interview with staff 6 revealed that the UAI accurately reflects the resident?s stairclimbing and mobility needs.
Plan of Correction:	1. Resident #5 ISP was updated to specify type of mechanical assistance needed for dressing and toileting. Resident #7 ISP updated to specify mechanical assistance needed for bladder incontinence, toileting, transferring and mobility. Resident #8 ISP updated to specify mechanical assistance and human supervision needed with stairclimbing and mobility. 2. Audit of ISP?s was completed by DON to confirm corrections made as needed. 3. DON/Charge Nurse re-educated regarding accuracy of ISP?s. DON/designee will audit 33% of ISP?s monthly, for 3 months, to ensure accuracy of services are documented. 4. Administrator/designee will conduct random monthly audits of 10% of ISP?s to ensure compliance. 5. 4/30/24
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 8 contains signed physician?s orders on 11/30/2023 for LISINOPRIL 5MG TABLET ? GIVE 1 TAB BY MOUTH EVERY DAY FOR HYPERTENSION ? HOLD IF BLOOD PRESSURE IS < 100. Per staff 6, the parameters exist for the systolic blood pressure reading. 2. The November 2023 MAR for resident 8 indicates that on 11/10/2023 that the resident?s blood pressure reading was 97/87; however, the MAR indicates that the LISINOPRIL was still administered. The December 2023 MAR for resident 8 indicates that on 12/22/2023 that the resident?s blood pressure reading was 85/58; however, the MAR indicates that the LINSINOPRIL was still administered.
Plan of Correction:	1. Resident #8 blood pressure parameters reviewed and DC?ed by Nurse Practitioner. 2. Audit was completed by DON on all resident blood pressure parameters. 3. Nursing staff re-educated on blood pressure parameters. 4. DON/designee to conduct weekly audits of blood pressure parameters and report findings to Administrator. 5. 2/29/24