Inspection Reports for Our Lady of the Valley
650 N Jefferson St, Roanoke, VA 24016, United States, VA, 24016
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Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Oct 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-11 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint related inspection triggered by allegations concerning resident care and related services; the complaint was not substantiated.
Report Facts
Number of residents present: 111
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 108
Deficiencies: 0
Sep 11, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in resident care and related services, and admission, retention, and discharge of residents.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found.
Report Facts
Number of resident records reviewed: 2
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 108
Deficiencies: 2
Sep 11, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-07-02 regarding allegations in resident care and related services.
Findings
The investigation supported the self-report of non-compliance with medication administration standards, specifically errors in medication administration and documentation. Violations were issued related to administering incorrect medication doses and failure to document actions taken after medication errors.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician or prescriber instructions, resulting in a resident receiving another resident's medication dose. |
| Facility failed to ensure medication administration staff documented actions taken in the resident's record following a medication error. |
Report Facts
Residents present: 108
Resident records reviewed: 2
Staff records reviewed: 1
Staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
May 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-07 regarding allegations related to building and grounds, and resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint #62394 was investigated with no substantiation of the allegations.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 113
Deficiencies: 0
Apr 15, 2025
Visit Reason
The inspection was a monitoring visit conducted by the Virginia Department of Social Services following a self-reported incident received on 2025-04-07 regarding allegations in resident care and related services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found during the inspection.
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Monitoring
Census: 113
Deficiencies: 4
Apr 1, 2025
Visit Reason
The inspection was a monitoring visit conducted on April 1 and April 15, 2025, following a self-reported incident received on March 20, 2025, regarding allegations in personnel and resident care and related services.
Findings
The investigation supported the self-report of non-compliance with multiple regulatory standards related to staff records, medication management, and medication administration errors. Violations were issued for failure to maintain proper staff documentation, improper medication administration, and allowing a provisional medication aide to work beyond the allowed 120-day period without passing required competency evaluations.
Deficiencies (4)
| Description |
|---|
| Failed to ensure personal and social data were maintained in staff records, including job description, qualifications, and medication aide provisional authorization. |
| Failed to implement portions of the medication management plan, including monitoring medication administration and ensuring staff qualifications. |
| Allowed a provisional medication aide to act beyond the 120-day provisional practice limit without passing the required competency evaluation. |
| Failed to ensure medications were administered according to physician's orders, resulting in a medication error where one resident received another resident's medication. |
Report Facts
Number of residents present: 113
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Medication error date: Mar 19, 2025
Medication administration audit start date: Apr 22, 2025
Medication pass observation start date: Apr 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff 1 | Provisional Registered Medication Aide | Named in findings related to medication aide provisional authorization and medication administration errors |
| Staff 2 | Interviewed staff who provided information about Staff 1's provisional status and medication error | |
| Staff 3 | Reported the medication error and involved in interviews | |
| Director of Nursing | Director of Nursing | Responsible for conducting staff retraining and audits related to medication administration |
Inspection Report
Renewal
Deficiencies: 2
Jan 27, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with standards related to fall risk assessments and documentation of fall incident analyses and interventions for resident 5. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that the fall risk rating was reviewed and updated after a fall. |
| The facility failed to document an analysis of the circumstances of falls and interventions initiated to prevent or reduce risk of subsequent falls. |
Report Facts
Dates of falls: 2
Inspection duration hours: 7.5
Inspection Report
Monitoring
Census: 107
Deficiencies: 0
Dec 5, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations related to admission, retention, and discharge of residents and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found during the inspection.
Report Facts
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
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Dec 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by VDSS Division of Licensing on 2024-11-11 regarding allegations related to admission, retention and discharge of residents, resident care and related services, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation supported some but not all allegations; non-compliance was found in the area of resident care and related services. A violation notice was issued related to failure to ensure individualized service plans (ISP) were signed and dated by required parties.
Complaint Details
The complaint was substantiated in part; evidence showed the ISP for resident 1 lacked required signatures after completion and updates. The resident had been discharged prior to inspection.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or designee and by the resident or legal representative upon completion and after any reviews or updates. |
Report Facts
Number of residents present: 107
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Monitoring
Census: 112
Deficiencies: 0
Oct 28, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found.
Report Facts
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of resident records reviewed: 0
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Oct 28, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-19 regarding allegations in the area of resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection concluded without identifying deficiencies.
Complaint Details
Complaint #60701 was investigated; the evidence did not substantiate the allegations of non-compliance.
Report Facts
Number of residents present: 112
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Renewal
Deficiencies: 2
Jan 18, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to determine compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards, specifically deficiencies related to individualized service plans (ISP) not fully specifying mechanical assistance needs and medication administration not following physician instructions.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that the individualized service plan (ISP) contained a description of identified needs from all sources, including the uniform assessment instrument (UAI), specifically lacking details on types of mechanical assistance needed for residents. |
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, as evidenced by administration of LISINOPRIL despite blood pressure readings below prescribed parameters. |
Report Facts
Inspection days: 2
ISP audit percentage: 33
ISP random audit percentage: 10
Weekly audits: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Named as the current inspector conducting the inspection |
| DON | Director of Nursing | Responsible for auditing ISPs and re-educating nursing staff |
| Nurse Practitioner | Reviewed and discontinued blood pressure parameters for resident #8 | |
| Staff 6 | Interviewed regarding resident care and medication administration |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Jun 13, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-05-05 regarding multiple resident care concerns at the facility.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified regarding failure to complete a preliminary plan of care within seven days prior to a resident's admission.
Complaint Details
Complaint #57420 was investigated and found not substantiated based on evidence gathered during the inspection.
Deficiencies (1)
| Description |
|---|
| 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 admission. |
Report Facts
Number of residents present: 21
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Renewal
Deficiencies: 15
Feb 21, 2023
Visit Reason
The inspection was a renewal inspection conducted to determine compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple areas of non-compliance including infection control practices, staff training deficiencies, incomplete or inaccurate resident records, medication management issues, and safety concerns such as unsecured resident records and hazardous materials storage. Plans of correction were provided for each deficiency.
Deficiencies (15)
| Description |
|---|
| Failed to implement infection control policy regarding blood glucose monitoring practices consistent with CDC recommendations. |
| Failed to ensure required annual continuing education for medication aides was completed. |
| Failed to ensure staff submitted tuberculosis risk assessment results prior to employment and annually. |
| Failed to ensure direct care staff were trained in methods of dealing with residents with aggressive behavior prior to care involvement. |
| Failed to ensure direct care staff received annual refresher training on aggressive behavior management. |
| Failed to complete or update uniform assessment instrument (UAI) to reflect residents' aggressive behaviors. |
| Failed to complete individualized service plans (ISPs) accurately and update them as required. |
| Failed to ensure ISPs were signed and dated by required parties. |
| Failed to record physician orders, services provided, and evaluations for residents receiving home health wound care. |
| Failed to keep all resident records in a locked area. |
| Failed to ensure accurate counts of controlled substances at shift changes. |
| Failed to ensure residents only keep medications in out-of-sight places if capable of self-administration per UAI. |
| Failed to ensure PRN medication orders included required details such as symptoms, dosage, time frames, and directions. |
| Failed to ensure operable windows were effectively screened. |
| Failed to ensure cleaning supplies and hazardous materials were stored in locked areas. |
Report Facts
Inspection duration: 8
Medication cart signature omissions: 4
Training hours required: 18
Medication aide continuing education hours: 4
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the renewal inspection |
| Staff 1 | Registered medication aide lacking required annual training and aggressive behavior refresher training | |
| Staff 2 | Direct care staff lacking aggressive behavior training prior to care involvement | |
| Staff 3 | Registered medication aide lacking required annual training and aggressive behavior refresher training | |
| Staff 4 | Staff lacking tuberculosis risk assessment documentation and aggressive behavior training | |
| Staff 6 | Staff interviewed confirming training and documentation deficiencies | |
| Staff 7 | Staff interviewed confirming training and documentation deficiencies | |
| Staff 8 | Staff interviewed regarding resident therapy status |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Sep 26, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-09-23 regarding failure to implement interventions to prevent or reduce resident falls and failure to adhere to resident requests for no medical treatment.
Findings
The investigation supported some of the allegations, specifically failure to implement interventions to prevent or reduce resident falls. Violations were identified related to failure to update the uniform assessment instrument (UAI) after significant changes in resident condition and failure to ensure the individualized service plan (ISP) included all identified resident needs, particularly fall risk interventions.
Complaint Details
The complaint was substantiated in part, specifically regarding failure to implement interventions to prevent or reduce resident falls. Other allegations were not fully supported.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that the uniform assessment instrument (UAI) was completed whenever there was a significant change in the resident's condition. |
| Facility failed to ensure that the individualized service plan (ISP) included all identified needs of the resident, including fall risk interventions from the hospice plan of care. |
Report Facts
Residents present: 90
Resident records reviewed: 1
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Conducted the inspection and is contact for questions |
Inspection Report
Monitoring
Deficiencies: 0
Jul 25, 2022
Visit Reason
The inspection was a monitoring visit to review staffing and supervision, resident care and related services, buildings and grounds, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The inspection found no violations with applicable standards or laws. The inspection summary will be posted publicly and a copy of the findings is required to be posted on the facility premises.
Inspection Report
Monitoring
Census: 90
Deficiencies: 2
Jun 21, 2022
Visit Reason
The inspection was a monitoring visit conducted to investigate a self-reported incident received on 2022-05-15 regarding resident elopement from the secure memory care unit.
Findings
The facility failed to ensure that doors leading to unprotected areas were properly monitored or secured, resulting in a resident exiting the secure unit unsupervised. The facility also failed to ensure adequate supervision of residents with specialized needs, including prevention of wandering and exit seeking behaviors.
Deficiencies (2)
| Description |
|---|
| Failed to ensure that doors leading to unprotected areas were monitored or secured through devices conforming to building and fire codes, including door alarms and staff oversight. |
| Failed to ensure supervision of resident schedules, care, and activities, including prevention of falls and wandering from the premises. |
Report Facts
Number of residents present: 90
Number of residents in secure unit: 22
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Renewal
Census: 90
Deficiencies: 10
Apr 12, 2022
Visit Reason
An unannounced renewal study was conducted to assess compliance with standards for assisted living facilities, including a tour, medication observation, record reviews, and staff interviews.
Findings
Multiple deficiencies were found including failure to ensure proper assessment for residents with serious cognitive impairment, inadequate night staffing in the special care unit, unsecured windows, expired or missing first aid certifications for staff, incomplete individualized service plans, improper medication storage and administration, incomplete documentation of rounds, and lack of emergency preparedness exercises.
Deficiencies (10)
| Description |
|---|
| Failed to ensure prior to admission that residents with serious cognitive impairment were properly assessed by an independent clinical psychologist or physician. |
| Failed to ensure at least two direct care staff members were awake and on duty during night hours in the special care unit when 22 or fewer residents were present. |
| Failed to have a protective device on a window in the special care unit to prevent residents from crawling through. |
| Failed to ensure all direct care staff maintained current certification in adult first aid within 60 days of employment. |
| Failed to ensure individualized service plans contained all required components. |
| Failed to ensure residents capable of self-administering medication had proper physician orders and secure medication storage. |
| Failed to provide medical procedures or treatments ordered by a physician according to instructions and document them. |
| Failed to ensure medication administration records contained all required components including date, time, and staff initials. |
| Failed to document rounds for residents with inability to use signaling devices. |
| Failed to ensure all staff participated in emergency preparedness exercises at least once every six months. |
Report Facts
Residents in care: 90
Staff certifications expired: 3
Dates with insufficient night staffing: 2
Residents with undocumented rounds: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 9, 2022
Visit Reason
The licensing inspector conducted an unannounced complaint inspection in response to a complaint received on 03/09/2022 regarding allegations of charges for services not being provided.
Findings
The investigation found insufficient information to support the allegations, determining the complaint to be not valid, with no violations resulting from the complaint investigation.
Complaint Details
Complaint was related to allegations of charges for services not provided; complaint was determined to be not valid with no violations found.
Inspection Report
Renewal
Census: 56
Deficiencies: 2
Mar 1, 2021
Visit Reason
A renewal inspection was initiated to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliance related to failure to coordinate hospice care plans and improper scheduling of fire and emergency evacuation drills across shifts within a quarter.
Deficiencies (2)
| Description |
|---|
| Failure to ensure that when hospice care is provided, the ALF and licensed hospice organization communicate and establish a coordinated plan of care included in the individualized service plan. |
| Failure to ensure that fire and emergency evacuation drills provided for each shift in a quarter were not conducted in the same month. |
Report Facts
Fire and emergency drills conducted: 4
Fire and emergency drills dates: 3
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