Our Lady of the Valley — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Our Lady of the Valley was inspected 24 times between March 1, 2021 and March 23, 2026 by the Virginia Department of Social Services. 12 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 44 violations under 35 distinct standards. 8 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 23 of these 24 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

03/31/2027

Administrator

Meagan Seale

Licensing inspector

Holly Copeland

Inspector phone

(540) 309-5982

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

March 23, 2026Inspection0 violations

Inspection dates

03/23/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 03/23/2026 from 12:00 PM – 01:15 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 03/10/2026 regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES Number of residents present at the facility at the beginning of the inspection: 103 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 1 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 did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 9, 2026Inspection1 violation

Inspection dates

02/09/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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: 02/09/2026 from 08:15 AM to 05:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 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 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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

22VAC40-73-640-A

Based on record review and staff interview, the facility failed to ensure that its medication management plan contained components to address procedures for preventing the use of outdated medications, as well as its procedures for ensuring accurate counts of all controlled substances.

Evidence

On the date of the inspection, LI observed medication administration by staff 1, staff 2, and staff 3. The LI also performed audits of the medication carts on the first, second, and third floors of the assisted living, as well as an audit of the medication cart in the memory care unit, which included checking for any expired medications and ensuring accurate counts of controlled substances.
The medication management plan provided by the facility on the date of inspection did not contain a documented procedure of how medication staff will ensure that medications are monitored for expiration.
An interview with staff 4 on the date of inspection revealed that the facility’s medication management plan is incomplete regarding monitoring for expired medications.
An interview with staff 4 and staff 5 on the date of inspection revealed that the facility’s medication management plan also does not contain a documented procedure of its expectation that medication staff are to document on the corresponding controlled substance log while also documenting the medication administration record (MAR) after a controlled substance is administered to a resident, in order to ensure accurate counts of controlled substances.

Plan of correction

-- Narcotics: 1. Immediate correction for the narcotic log was completed while inspector was in building. 2. Audit performed for narc log accuracy by using the EMAR. All RMAs and nurses will complete a med pass observation by 2/24/26. 3. Education to be provided to med staff and will include narcotic admin and the narcotic admin process including signing of the narcotic log at time of narcotic admin. 4. The DON/Designee will complete 3 random med pass observations weekly x 4 weeks and perform weekly audits x 4 weeks comparing narcotic documentation on MAR to narcotic log signature. 5. POC will be taken to next quarter’s QA. After completion of POC, will continue to follow med mgmt policy with procedure to ensure staff awareness of documenting on the controlled substance log and documenting on the EMAR, after a controlled substance is administered. In addition to Med Mgmnt Policy, OLOV will adopt a new addendum for their own procedures. -- Addendum for Our Lady of the Valley- Narcotics 1. Nurse managers will complete random med pass observations and MAR to narcotic sign out checks monthly. Nurse manager will ensure staff awareness of to document on controlled substance log and documenting on the EMAR, after a controlled substance is admin. -- Expired Meds: 1. Immediate correction for expired meds completed while inspector was in the building. 2. Audit was performed on all med carts to check for any other expired meds, none found. 3. Education to be provided regarding expired meds and demonstration to check for expired meds will be completed and will include labeling meds when opened and noting per pharmacy guidance of how long until meds are expired. Pharmacy expiration sheets will be placed on med carts for guidance (insulins/eyedrops/nose sprays/inhalers/nebulizers etc.) 4. DON/Designee will monitor med carts for expired med 2x weekly x 4 weeks 5. POC will be taken to next quarter’s QA. After completion of POC, will continue to follow our med mgmnt policy with procedure to ensure documented procedure on monitoring meds for expirations. In addition to Med Management Policy, OLOV will adopt a new addendum for their own procedures. -- Addendum for Our Lady of the Valley - Expired Meds 1. Nurse managers will complete weekly med cart audits. 2. Education to be provided regarding expired meds and how to check for expired meds. Education to include labeling meds when opened and noting per pharmacy guidelines how long until med expires. Education to be reviewed during med pass observations. -- Addendum procedure for OLOV - Narcotics 1. Nurse managers will complete random med pass observations monthly. Nurse manager will ensure staff awareness of the procedure to document on the controlled substance log and documenting on the EMAR, after a controlled substance is admin. -- Addendum procedure for OLOV - Expired Meds 1. Nurse managers will complete weekly med cart audits. 2. Education to be provided regarding expired meds and demonstration of how to check for expired meds and will include labeling meds when opened and noting per pharmacy guidelines when a medication expires. Education will be reviewed during med pass observations.

January 13, 2026Inspection0 violations

Inspection dates

01/13/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 01/13/2026 from 10:15 AM to 11:45 AM 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 01/08/2026 regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES Number of residents present at the facility at the beginning of the inspection: 101 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: 1 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 3 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 did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 13, 2026Complaint survey0 violations

Inspection dates

01/13/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint 64236 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/13/2026 from 10:15 AM to 11:45 AM 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 10/28/2025 regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES Number of residents present at the facility at the beginning of the inspection: 101 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 21, 2025Complaint survey0 violations

Inspection dates

10/21/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint 64077 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/21/2025 from 10:30 AM to 11:30 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 10/11/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 11, 2025Inspection2 violations

Inspection dates

09/11/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring – Self-report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/11/2025 from 11:00 AM to 01:30 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 07/02/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 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 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

22VAC40-73-680-J

Based on record review and staff interview, the facility failed to ensure that in the event of a medication error, medication administration staff shall document actions taken in the resident’s record.

Evidence

On 07/02/2025, LI received a self-reported incident which indicated that during the 09:00 AM medication pass on the same date, staff 1 administered to resident 1 a medication belonging to resident 2. The self-report indicated that resident 1 was supposed to receive 10 MG of OXYCODONE during the 09:00 AM medication pass; however, resident 1 instead received 5 MG of OXYCODONE, the dose belonging to resident 2, which resulted in no adverse effects.
The same self-report also indicated that when staff 1 realized that the wrong medication was given to resident 1, she contacted staff 3. In addition, the self-report indicated that the physician for resident 1 was also contacted and gave an order to give resident 1 half of her OXYCODONE 10 MG (= 5 MG) to ensure that she received her full dosage of 10 MG.
Aside from the self-reported incident by the facility on 07/02/2025, the facility’s record for resident 1 did not contain documentation of the order that was given by her physician in response to the medication error, nor was there documentation that staff had followed the order.
An interview with staff 2 revealed that, upon speaking with staff 3, the order given by resident 1’s physician to give resident 1 half of her OXYCODONE 10MG (= 5MG) to ensure that she had received her full dose of 10MG, was followed but had not been documented.

Plan of correction

1.Staff Retraining: All medication administration staff will undergo mandatory retraining on proper medication administration procedures, emphasizing verification of resident identity and medication orders before administration. Training will be conducted by the facility’s Director of Nursing and completed by 10/03/2025. 2.An audit of medication administration records (MARs) for all residents was completed on 09/22/2025 to ensure that any physician orders related to medication errors were properly documented. No additional discrepancies were identified. 3. Education: All medication administration staff were educated on the facility’s Medication Administration Policy, with emphasis on the requirement to document all physician orders and follow-up actions in the resident record. Education will be conducted by the Director of Nursing. 4. Audits and Monitoring: Weekly audits of 10 randomly selected Medication Administration Records (MARs) to ensure that documentation of physician orders and follow-up actions are complete and accurate. Audits will be conducted by the Director of Nursing and will begin on 09/29/2025 and continue for 4 weeks.

22VAC40-73-680-D

Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with physician or other prescriber’s instructions.

Evidence

On 07/02/2025, LI received a self-reported incident which indicated that during the 09:00 AM medication pass on the same date, staff 1 administered to resident 1 a medication belonging to resident 2. The self-report indicated that resident 1 was supposed to receive 10 MG of OXYCODONE during the 09:00 AM medication pass; however, resident 1 instead received 5 MG of OXYCODONE, the dose belonging to resident 2, which resulted in no adverse effects.
During the on-site follow-up on 09/11/2025, the record for resident 1 contained signed physician’s orders for OXYCODONE-ACETAMINOPHEN 10MG-325MG TAB – Give 1 tab by mouth every 4 hours as needed for pain. The record for resident 2 contained signed physician’s orders for OXYCODONE IMMEDIATE 5MG – Take 1 tab by mouth every 4 hours as needed for pain. An interview with staff 2 on the date of inspection confirmed that resident 1 received resident 2’s OXYCODONE IMMEDIATE 5MG TAB instead of the OXYCODONE-ACETAMINOPHEN 10MG-325MG TAB that resident 1 had been prescribed. Staff 2 also confirmed that there were no adverse effects as a result.

Plan of correction

1. Staff Retraining: All medication administration staff will undergo mandatory retraining on proper medication administration procedures, emphasizing verification of resident identity and medication orders before administration. Training will be conducted by the facility’s Director of Nursing and completed by 09/30/2025. 2. Conduct Weekly Med Pass Observation: One weekly medication pass observation will be conducted to ensure proper procedures are being followed, including verifying the correct medication, resident, and dosage. Any deviations from protocol will be addressed immediately with follow-up education and retraining as needed. Med pass observations will be conducted by the Administrator and will begin 09/29/2025 and will continue for 4 weeks. 3. Audits and Monitoring: Weekly audits of 10 randomly selected Medication Administration Records (MARs) will be conducted by the DON or designee to ensure accurate administration and documentation. Audits will begin on 09/29/2025 and continue for 4 weeks.

September 11, 2025Inspection0 violations

Inspection dates

09/11/2025

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 09/11/2025 from 11:00 AM to 01:30 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 08/24/2025 regarding allegations in the area(s) of: Resident care and related services; Admission, retention, and discharge of residents Number of residents present at the facility at the beginning of the inspection: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 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 did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 29, 2025Complaint survey0 violations

Inspection dates

05/29/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint # 62394 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/29/2025 from 11:00 AM to 12:00 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 05/07/2025 regarding allegations in the area(s) of: Building and grounds; Resident care and related services Number of residents present at the facility at the beginning of the inspection: 107 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 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 did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 15, 2025Inspection0 violations

Inspection dates

04/15/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 04/15/2025 from 11:30 AM to 12:45 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 04/07/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 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 did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 1, 2025Inspection4 violations

Inspection dates

04/01/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 04/01/2025 from 10:45 AM to 12:30 PM 04/15/2025 from 11:30 AM to 12:45 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 03/20/2025 regarding allegations in the area(s) of: Personnel; Resident care and related services Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 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 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

22VAC40-73-680-D

Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

On 03/20/2025, LI received a self-reported incident from staff 3 which indicated that resident 1’s medication was administered to resident 2 on 03/19/2025 by staff 1.
An interview with staff 2 during the on-site follow-up at the facility on 04/01/2025, revealed that resident 1 and resident 2 both have OXY medications for pain; however, resident 2’s OXY medication also contains ACETAMINOPHEN. Staff 2 indicated that the medication error from 03/19 was initially identified at shift change when resident 1 and resident 2’s narcotic medication totals differed from physical counts to documented counts for their OXY medications.
During the 04/01/2025 on-site follow up, the record for resident 1 contained physician’s orders, signed 02/04/2025, for OXYCODONE IMMEDIATE 10 MG TABLET – TAKE 1 TABLET BY MOUTH EVERY 12 HOURS – 9 AM, 9 PM FOR CHRONIC PAIN.
Alternately, the record for resident 2 contained physician’s orders, signed 02/21/2025, for OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET – 1 TABLET BY MOUTH THREE TIMES A DAY FOR PAIN – 12 AM, 8 AM, and 4 PM.
During the same on-site follow-up, LI reviewed the service notes for resident 2 and the MEDICATION DISCREPANCY REPORT which also confirmed that resident 2 did not receive her prescribed OXYCODONE ACETAMINOPHEN 10 MG-325 MG TABLET but instead received resident 1’s OXYCODONE 10 MG on 03/19 at 5 PM.

Plan of correction

1. Staff Retraining: All medication administration staff will undergo mandatory retraining on proper medication administration procedures, emphasizing verification of resident identity and medication orders before administration. Training will be conducted by the facility’s Director of Nursing and completed by 05/06/2025. 2. Conduct Weekly Med Pass Observations: Weekly medication pass observations will be conducted by the nursing leadership team to ensure proper procedures are being followed, including verifying the correct medication, resident, and dosage. Any deviations from protocol will be addressed immediately with follow-up education and retraining as needed. Med Pass observations will begin 04/28/2025. 3. Audits and Monitoring: Audits and Monitoring: Weekly audits of 15 randomly selected Medication Administration Records (MARs) will be conducted by the DON or designee to ensure accurate administration and documentation. Audits will begin on 04/22/2025 and continue for 4 weeks to confirm compliance.

22VAC40-73-250-C

Based on record review and staff interview, the facility failed to ensure that the following personal and social data shall be maintained in a staff record: Verification that the staff person has received a copy of current job description; documentation of qualifications of employment related to the staff person’s position; verification of medication aide provisional authorization.

Evidence

During the on-site follow-up inspection on 04/01/2025, the record for staff 1 indicated that she is full-time PCA, effective 03/18/2024.
An interview with staff 2 and staff 3 revealed that staff 1 is actually working as a registered medication aide (RMA); however, LI was unable to locate a current job description for an RMA or a certificate for completion of the 68-hour RMA training program in staff 1’s record.
Staff 2 clarified to LI that staff 1 has been working as a provisional RMA; however, the record for staff 1 did not contain the medication aide provisional authorization letter which was later provided by staff 2.

Plan of correction

1. Update Staff Records: Staff 1 has since been terminated; however, the staff’s record has been updated on 04/01/2025 to include: o A copy of the medication aide provisional authorization letter. 2. Record Audit: The facility administrator will conduct a full audit of all staff records by 04/30/2025 to ensure compliance with 22VAC40-73-250-C, verifying job descriptions, qualifications, and certifications. 3. Staff Training: HR and supervisory staff will be trained by 05/06/2025 on maintaining complete and accurate staff records per regulatory requirements.

22VAC40-73-640-A

Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding: Methods for monitoring medication administration and the effective use of the medication administration records (MARs) for documentation; and the facility failed to include all regulatory requirements in its methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670;

Evidence

The facility’s most current medication management plan, revised 05/31/2023, under ADMINISTRATION OF MEDICATIONS procedure point 2, indicates that MEDICATION ADMINISTRATION RECORDS (MARs) OR ELECTRONIC MARs SHALL CONTAIN ANY MEDICATION ERRORS OR OMISSIONS.
On 03/20/2025, LI received a self-reported incident from staff 3 which indicated that resident 1’s medication was administered to resident 2 on 03/19/2025 by staff 1.
During the on-site follow-up at the facility on 04/01/2025, an interview with staff 2, and a review of the MEDICATION DISCREPANCY REPORT confirmed that resident 2 did not receive her prescribed OXYCODONE ACETAMINOPHEN 10 MG-325 MG TABLET but instead received another resident’s OXYCODONE 10 MG on 03/19 at 5 PM.
The March 2025 MAR for resident 2 did not contain documentation of the medication error where resident 2 had received resident 1’s medication on 03/19 at 5 PM.
The facility’s most current medication management plan, revised 06/03/2019, under the ADMINISTRATION OF MEDICATIONS: EMPLOYEE REQUIREMENTS policy, states that MEDICATION ADMINISTRATION EMPLOYEES MUST HAVE SUCCESSFULLY COMPLETED THE STATE REQUIRED MEDICATION AIDE TRAINING AND BE A REGISTERED MEDICATION AIDE GOVERNED BY THE DEPARTMENT OF HEALTH PROFESSIONS; however, that same policy does not include the requirements of 22VAC40-73-670, regarding 120-day provisional medication aide practice time limit, as indicated in point # 9 of the regulation cited.

Plan of correction

1. Verification of Medication Aide Licenses: The facility administrator will conduct an immediate review of all medication aides’ records by 04/02/2025 to verify active licensure status with the Virginia Board of Nursing, ensuring compliance with 22VAC40-73-670. 2. Adherence to Medication Management Plan: The facility will continue to follow its current medication management plan, which includes: • Verification of active medication aide licenses prior to allowing any staff member to administer medications. • Strict adherence to medication management plan, suggesting no individual will pass medications without active RMA or LPN/RN licensure. Thus, remaining in compliance with 22VAC40-73-670, ensuring no individual is permitted to pass medications without proper licensure. 3. Staff Training on Licensure Requirements: All medication administration staff and supervisors will be trained by 05/06/2025 on the requirements of 22VAC40-73-670, emphasizing the necessity of maintaining an active medication aide license. 4. Ongoing Monitoring and Audits: The DON or designee will implement a monthly audit process, starting 04/01/2025, to confirm that all medication aides have active licenses and are in compliance with regulatory requirements. Audit results will be reviewed with the facility administrator to ensure ongoing adherence.

22VAC40-73-670-2

Based on record review and staff interview, the facility failed to ensure that any applicant for registration as a medication aide who has provided to the Virginia Board of Nursing

Evidence

of successful completion of the education or training course required for registration may act as a medication aide on a provisional basis for no more than 120 days before successfully completing any required competency evaluation. However, upon notification of failure to successfully complete the written examination after three attempts, an applicant shall immediately cease acting as a medication aide. EVIDENCE:
During the on-site follow-up inspection on 04/01/2025, an interview with staff 2 revealed that staff 1 is a provisional registered medication aide (RMA).
Staff 1’s medication aide provisional authorization letter from the Virginia Department of Health Professions indicated an effective date of 09/11/2024, and staff 2 confirmed that staff 1 has been working as a provisional RMA since that time but has not passed her registered medication aide examination, and her 120 days to practice as a provisional RMA had expired on 01/09/2025.

Plan of correction

1. Immediate Removal from Medication Duties: Staff 1 has been immediately removed from medication administration duties, effective 04/01/2025. 2. 2. Adherence to Medication Management Policy: The facility will ensure compliance with current medication management plan, which requires that all individuals administering medications be either a licensed Registered Medication Aide (RMA) or a licensed nurse. No staff member will be permitted to pass medications under a provisional license. This ensures ongoing compliance with 22VAC40-73-670. 3. Staff Record Audit: The facility administrator will audit all medication aide records by 04/01/2025 to verify current registration status and ensure no other provisional aides work in the facility. 4. Staff Training on Licensure Requirements: All medication administration staff and supervisors will be trained by 05/06/2025 on the requirements of 22VAC40-73-670, emphasizing the necessity of maintaining an active medication aide license.

January 27, 2025Inspection2 violations

Inspection dates

01/27/2025

Areas reviewed

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: 01/27/2025 from 08:15 AM to 03:45 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

22VAC40-73-325-C

Based on record review and staff interview, the facility failed to ensure that, should a resident fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.

Evidence

The record for resident 5 contained SERVICE NOTES of falls on 09/13/2024 and 12/04/2024; however, the record did not contain documentation of an analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce risk of subsequent falls.
An interview with staff 6 did not result in locating this documentation after resident 5’s 09/13 and 12/04 falls.

Plan of correction

1. An internal audit will be conducted on all resident falls from the past six months to ensure that the Individual Service Plan (ISP) have been properly updated to reflect interventions aimed at preventing or reducing the risk of subsequent falls. (To be corrected by 02/28/2025) 2. Resident 5’s ISP was updated to document interventions that were initiated to prevent or reduce risk of subsequent falls when a resident who meets the criteria for assisted living care falls. (To be corrected by 02/03/2025) 3. Nursing personnel will be in-serviced on documenting interventions that were initiated to prevent or reduce the risk of subsequent falls when a resident who meets the criteria for assisted living care falls. In addition, nursing personnel will be trained on the fall management procedures. The Director of Nursing will ensure that the intervention form is in place after each fall. (To be corrected by 03/15/2025) 4. The Director of Nursing or designee will be responsible for verifying weekly that interventions that were initiated to prevent or reduce the risk of subsequent falls when a resident who meets the criteria for assisted living care falls are documented. The issue will be discussed at the quarterly QAPI meeting until resolved (To be corrected by 04/15/2025)

22VAC40-73-325-B

Based on record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall.

Evidence

During the on-site renewal inspection, the record for resident 5 contained staff charting notes “SERVICE NOTES” which indicated that resident 5 had fallen on 12/04/2024, striking the left side of her back. As a result of assessment by staff 5, a licensed healthcare professional, the resident was administered medication for pain, vital signs were obtained and charted, and the resident’s POA was notified.
Upon a review of resident 5’s FALL RISK ASSESSMENT form, LI could not confirm that the fall on 12/04/2024 was documented and reviewed on this form due to the most recent assessment date being blank.
An interview with staff 6 did not result in locating where the fall was assessed for 12/04.

Plan of correction

1. An internal audit will be conducted on all resident falls and corresponding fall risk assessments from the past six months to ensure that each assessment has been completed appropriately. (To be corrected by 02/28/2025) 2. A fall risk assessment for Resident 5 was completed following the fall on 12/04/2024, in accordance with the appropriate procedures. (To be corrected by 02/02/2025) 3. Education will be completed with all nursing personnel of the ALF that a fall risk evaluation will be completed after each fall incident sustained by the residents. (To be corrected by 03/15/2025) 4. The Unit Manager/Designee will verify weekly that a fall risk assessment has been completed following each incident and will report to the DON/Designee. If a fall risk assessment has not been completed, the Director of Nursing/Designee will re-educate the responsible staff member and verify that the assessment is completed. The issue will be discussed at the quarterly QAPI meeting until resolved. (To be corrected by 04/15/2025)

December 5, 2024Complaint survey1 violation

Inspection dates

12/05/2024

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint 60823 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/05/2024 from 11:00 AM to 01:00 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 11/11/2024 regarding allegations in the area(s) of: -ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS -RESIDENT CARE AND RELATED SERVICES -ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Number of residents present at the facility at the beginning of the inspection: 107 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: Resident no longer lives at the facility on date of inspection. 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: - RESIDENT CARE AND RELATED SERVICES 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

22VAC40-73-450-E

Based on record review and staff interview, 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, upon completion and after any reviews or updates to the ISP.

Evidence

The record for resident 1 contained a comprehensive ISP with a 01/18/2024 completion date. The same ISP also contained updates on 09/09/2024, 10/23/2024, and 11/06/2024 due to changes in resident behavior.
Alternately, the ISP for resident 1 did not contain signatures by resident 1 or the resident’s legal representative after its completion on 01/18/2024 nor after it was updated on 09/09, 10/23, and 11/06.
An interview with staff 1 on the date of the on-site complaint investigation revealed that there is no other documentation to confirm that either resident 1 or the resident’s legal representative had signed the ISP at any time.

Plan of correction

1. Resident 1 discharged prior to inspection. 2. An internal audit has been conducted on all resident ISP’s to ensure each ISP includes the signature of either the resident or the resident’s legal representative. (To be corrected by 03/31/2025) 3. DON has been educated on the accuracy of the ISP’s and the required signatures. DON/designee will conduct quarterly audits for one year to ensure each ISP has the required signatures. (To be corrected by 03/31/2025) 4. Administrator/designee will be responsible for conducting audits on ISP’s every six months for one year to ensure compliance. (To be corrected by 03/31/2025)

December 5, 2024Inspection0 violations

Inspection dates

12/05/2024

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 12/05/2024 from 11:00 AM to 01:00 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 11/06/2024 regarding allegations in the area(s) of: ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS; ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Number of residents present at the facility at the beginning of the inspection: 107 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 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 did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 28, 2024Complaint survey0 violations

Inspection dates

10/28/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint # 60701 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/28/2024 from 01:30 PM to 02:30 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 08/19/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 112 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 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 did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 28, 2024Inspection0 violations

Inspection dates

10/28/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 10/28/2024 from 01:30 PM until 02:30 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 10/02/2024 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 112 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 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 did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 18, 2024Inspection2 violations

Inspection dates

01/18/2024

Areas reviewed

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

22VAC40-73-680-D

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

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.
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

22VAC40-73-450-C

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

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.
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.
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

June 13, 2023Complaint survey1 violation

Inspection dates

06/13/2023

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint # 57420 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/13/2023 from 01:30 PM until 04:00 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 05/05/2023 regarding allegations in the area(s) of: Multiple resident care concerns. Number of residents present at the facility at the beginning of the inspection: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can 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

22VAC40-73-450-A

Based on record review and staff interview, the facility failed to ensure that a preliminary plan of care to address a resident’s needs was completed on or within seven days prior to a resident’s admission.

Evidence

The record for resident 1 indicated a date of admission of 03/08/2023 and the record also indicated that the resident was hospitalized on 03/12/2023 but did not return to the facility after that time.
On the date of inspection on 06/13/2023, the record for resident 1 did not contain a preliminary plan of care despite resident 1 living at the facility from 03/08 until 03/12.
An indication by staff 1 on 07/05/2023 revealed that the facility did not complete a preliminary plan of care for resident 1 on or within seven days prior to admission.

Plan of correction

1. Resident 1 did not have a preliminary care plan completed. 2. An audit was completed to identify residents who had a preliminary plan of care, on or within seven days prior to the day of admissions. 3. DON/designees were reeducated that new admissions must have a preliminary plan of care in place upon admission or within seven days prior to the day of admission. Effective July 1, 2023, all new admission will have a preliminary care plan in place, on the day of or prior to admission. The preliminary care plan will be submitted to the Assistant Administrator on the day of admission for 3 months, to ensure compliance was achieved. 4. Executive Director/designee will audit 50% of all new admissions records for completion of the preliminary care plan and report compliance to QA.

February 21, 2023Inspection15 violations

Inspection dates

02/21/2023

Areas reviewed

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

22VAC40-73-560-E

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.

22VAC40-73-210-D

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

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.
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.
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.
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.

22VAC40-73-660-B

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

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.
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.
Resident 2 informed collateral 1 and staff 3 that she has been using the inhaler due to shortness of breath and wheezing.
Collateral 1 and staff 3 noted that the inhaler contained an expiration date of 09/2022.
The record for resident 2 did not contain a physician’s order that the resident can keep at bedside and self-administer Albuterol Sulfate.
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.

22VAC40-73-100-C-2

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

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.”
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.

22VAC40-73-860-I

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

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.
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.

22VAC40-73-640-A

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

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.”
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.
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.

22VAC40-73-680-K

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

Collateral 1 observed a bottle of PRN Naxolone HCL 4MG spray for resident 13 in the medication cart.
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.
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.

22VAC40-73-250-D

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

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.
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:
The record for staff 1 contained a TB screening form dated 05/25/2021.
The record for staff 3 contained a TB screening form dated 05/06/2021.
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.

22VAC40-73-480-E

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

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.
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.
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.

22VAC40-73-450-C

Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) were completed as required.

Evidence

The ISP for resident 2, dated 09/27/2022, indicates that the resident is receiving physical and occupational therapy.
Interview with staff 8 revealed that the resident is not currently receiving physical and occupational therapy.
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.
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.

22VAC40-73-270-1

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

Facility documentation indicates aggressive behaviors presented by resident 8 on 01/25/2023, 01/28/2023, and 01/31/2023.
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.
This LI observed staff 2 providing direct care services and medication administration in the facility’s memory care unit on the date of inspection.
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.
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.

22VAC40-73-860-D

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.

22VAC40-73-440-D

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.

22VAC40-73-270-4

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

Facility documentation indicates aggressive behaviors presented by resident 8 on 01/25/2023, 01/28/2023, and 01/31/2023.
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.
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.
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.

22VAC40-73-450-E

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

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.
The ISP for resident 7, updated 01/17/2023, was not signed and dated by the resident or the resident’s legal representative.
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.

September 26, 2022Complaint survey2 violations

Inspection dates

09/26/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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

22VAC40-73-450-C

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

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.
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.
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.
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.

22VAC40-73-440-A

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

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.
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.

July 25, 2022Inspection0 violations

Inspection dates

07/25/2022

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 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: 07/25/2022 - 01:30 PM – 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 21, 2022Inspection2 violations

Inspection dates

06/21/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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

22VAC40-73-460-D

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

Resident 1 moved in to the facility’s memory care unit on 11/17/2021.
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.
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”.
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”.
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.
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.
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.

22VAC40-73-1150-A

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

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”.
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.
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.

April 12, 2022Inspection10 violations

Inspection dates

04/12/2022

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity

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

22VAC40-73-680-I

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.

22VAC40-73-450-C

450-C Based on record review, the facility failed to ensure that the individualized service plan (ISP) contained all required components.

Evidence

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 published by VDSS.

22VAC40-73-260-A

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

The record for staff 1, hired 03/11/2002, contained certification of Adult CPR/AED/Basic First Aid training which expired 09/2021.
The record for staff 2, hired 08/25/2000, contained certification of Basic Life Support training which expired 08/2019.
The record for staff 5, hired 11/22/2021, did not contain documentation of having completed any adult first aid training.
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.

22VAC40-73-1090-A

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.

22VAC40-73-1130-C

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

Interview with staff 6 indicated that the facility’s special care unit housed 18 residents on the date of inspection.
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.
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.

22VAC40-73-680-E

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

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.

22VAC40-73-1150-B

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

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.

22VAC40-73-990-C

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.

22VAC40-73-930-D

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

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.

22VAC40-73-660-B

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

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.
Resident 10 stated that she does not have physician orders for these, and staff is not aware they are in her room.
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.
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.

March 9, 2022Complaint survey0 violations

Inspection dates

03/09/2022

Areas reviewed

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical assistance

680-E

Comments

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 03/09/2022. The LI reviewed documentation, toured the facility, and conducted interviews of resident and staff members relating to allegations of charges for services that are not being provided. The information gathered during the investigation was insufficient to support the allegations, so the complaint is determined to be “not valid.” There are no violations resulting from this complaint investigation. Please sign, date, and return this notice to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 1, 2021Inspection2 violations

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS

Technical assistance

325-B, 440-C, 480-E

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 3/1/2021 and concluded on 3/2/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 56. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-450-D

450-D Based on record review, the facility failed to ensure that when hospice care is provided to a resident, the ALF and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).

Evidence

The ISP for resident 4, dated 1/15/2021, indicated that the resident is receiving palliative services and end of life care by Good Samaritan hospice; however, the ISP did not indicate which services that hospice was providing.

Plan of correction

1. The ISP for resident #4 was updated to indicate the services established in the contract with Good Samaritan Hospice. 2. All resident service plans indicating contracted services were audited to inspect for individualized service needs. 3. The DON/Designee will audit service plans monthly to ensure individualized needs are explained thoroughly. 4. The Administrator/Designee will ensure compliance.

22VAC40-73-970-A

970-A Based on record review, the facility failed to ensure that fire and emergency evacuation drills provided for each shift in a quarter were not conducted in the same month.

Evidence

The facility’s fire and emergency drill documentation indicated that the past three fire and emergency drills occurred on 2/19/2021 on 3rd shift, 1/28/2021 on 2nd shift, and 12/23/2021 on 3rd shift.
Interview with staff 5 indicated that a 1st shift fire and emergency drill occurred on 1/25/2021; however, this occurred during the same month as the 2nd shift drill.

Plan of correction

1. The facility completed four fire drills within the last quarter. The maintenance team was in-serviced on fire drill regulations and conducting monthly drills on a different shift each month. 2. The Facilities Director/Designee will schedule planned drills in advance to ensure a different shift is covered each month within the quarter. 3. The Facilities Director/Designee will audit the fire and safety manual quarterly to ensure drills are conducted timely. 4. The Administrator/Designee will ensure compliance.