Inspection Reports for
Our Lady of the Valley
650 N Jefferson St, Roanoke, VA 24016, United States, VA, 24016
Back to Facility Profile4 Reports · 1 Summary
Inspection Summary
24 inspections covered, Mar 2021 – Mar 2026.
Inspection Reports Summary
Visit Reason
This report covers 24 inspections of Our Lady of the Valley from March 1, 2021 to March 23, 2026 by the Virginia Department of Social Services.
Complaint Details
Eight inspections were prompted by complaints. Investigations found some supported and some unsupported allegations. Violations were issued only when supported by evidence.
Findings
Across that history VDSS cited 44 violations under 35 distinct standards. 12 of 24 visits ended with violations cited and 12 with none. 8 inspections were prompted by a complaint.
Violations (38)
22VAC40-73-640-A: Medication management plan lacked procedures for preventing outdated meds and ensuring accurate controlled substance counts.
22VAC40-73-680-J: Medication error documentation missing for actions taken after wrong medication given.
22VAC40-73-680-D: Medications not administered per physician's instructions; wrong dose given to resident.
22VAC40-73-250-C: Staff record missing job description, qualifications, and provisional authorization verification.
22VAC40-73-640-A: Medication management plan incomplete on monitoring MARs and staff qualifications per regulation.
22VAC40-73-670-2: Provisional medication aide exceeded 120-day practice limit without passing competency evaluation.
22VAC40-73-325-C: No documentation of fall analysis and interventions after resident falls.
22VAC40-73-325-B: Fall risk rating not reviewed or updated after a fall.
22VAC40-73-450-E: Individualized service plan (ISP) not signed and dated by required parties after updates.
22VAC40-73-450-C: ISP lacked description of identified needs from all sources including uniform assessment instrument.
22VAC40-73-560-E: Resident records not kept in a locked area; rolling cart unlocked with records visible.
22VAC40-73-210-D: Medication aides lacked required annual continuing education in medication administration.
22VAC40-73-660-B: Resident kept medication out of sight without physician order or capability to self-administer.
22VAC40-73-100-C-2: Blood glucose meters not labeled with resident names as required by infection control policy.
22VAC40-73-860-I: Cleaning supplies and hazardous materials stored in unlocked rooms.
22VAC40-73-640-A: Medication management policy not fully implemented for controlled substance counts at shift changes.
22VAC40-73-680-K: PRN medication orders lacked required symptom indications, dosage, timing, and directions.
22VAC40-73-250-D: Staff failed to submit tuberculosis risk assessment results prior to or within seven days of employment.
22VAC40-73-480-E: Physician orders and evaluations for rehabilitative services not documented in resident records.
22VAC40-73-450-C: Individualized service plans contained discontinued or inaccurate therapy and service orders.
22VAC40-73-270-1: Direct care staff lacked training in managing residents with aggressive or agitated behavior.
22VAC40-73-860-D: Operable windows not effectively screened in resident rooms.
22VAC40-73-440-D: Uniform assessment instrument not updated for private pay residents after significant condition changes.
22VAC40-73-270-4: Direct care staff lacked annual refresher training on managing aggressive or agitated residents.
22VAC40-73-450-E: Individualized service plans not signed and dated by licensee, administrator, or resident/legal representative.
22VAC40-73-460-D: Failed to supervise resident schedules and activities to prevent falls and wandering.
22VAC40-73-1150-A: Doors to unprotected areas not monitored or secured with alarms or staff oversight.
22VAC40-73-325-A: Preliminary plan of care not completed on or within seven days prior to resident admission.
22VAC40-73-680-I: Medication administration record missing required components including date/time and staff initials.
22VAC40-73-260-A: Direct care staff lacked current certification in adult first aid within required timeframe.
22VAC40-73-1090-A: Assessment for serious cognitive impairment incomplete or inaccurate for memory care admission.
22VAC40-73-1130-C: Less than two awake direct care staff on duty during night hours in special care unit.
22VAC40-73-680-E: Medical procedures ordered by physician not provided or documented as required.
22VAC40-73-1150-B: Window in special care unit lacked protective device preventing wide opening.
22VAC40-73-990-C: No documentation of emergency procedure practice exercises for staff.
22VAC40-73-930-D: Rounds not documented for residents unable to use signaling devices during specified times.
22VAC40-73-660-B: Resident kept medications in room without physician order and unable to self-administer.
22VAC40-73-680-D: Medications not administered per physician’s instructions; wrong medication given to resident.
Report Facts
Violations cited: 44
Distinct standards: 35
Inspections on page: 24
Inspections with violations: 12
Complaint visits: 8
Individual Reports
One document per inspection visit.
Inspection Report — Aug 25, 2023
Routine
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to assess compliance with care plan development, medication administration, and resident safety protocols at Our Lady of the Valley nursing home.
Findings
The facility failed to hold timely care plan meetings for one resident, did not follow physician's orders for medication administration times for the same resident, and failed to provide adequate supervision and use of assistive devices during transfers for another resident, resulting in injury.
Violations (3)
Failed to ensure care plan meetings were held in a timely manner for one of 21 residents, Resident #221.
Failed to follow physician's orders to change administration times for medication Voltaren gel for Resident #221.
Failed to ensure adequate supervision and use of mechanical lift with two or more staff members during transfer of Resident #222, resulting in a tibial fracture.
Report Facts
Residents in survey sample: 21
Care Plan Conference Summary forms: 6
Care plan progress notes: 4
Medication administration times: 3
Pain medication schedule: 4
Pain medication as needed interval: 2
Antibiotic frequency: 2
X-ray dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Reported details of Resident #222's transfer incident and subsequent observations |
| LPN #1 | Licensed Practical Nurse | Reported use of Hoyer lift for Resident #222 and observations after injury |
| DON | Director of Nursing | Provided explanations regarding care plan meetings and medication administration issues |
| Administrator | Discussed concerns regarding care plan meetings and medication administration times | |
| Medical Doctor | Facility Medical Doctor | Assessed Resident #222 after injury and provided medical opinions |
Inspection Report — Aug 25, 2023
Complaint Investigation
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to investigate complaints related to medication administration, nutritional care, and pharmacy review processes for residents at the facility.
Complaint Details
The visit was complaint-related, focusing on medication administration errors, nutritional care deficiencies, and lack of physician review of pharmacy recommendations. The complaints were substantiated with findings of minimal harm or potential for harm.
Findings
The facility failed to follow physician's orders for medication administration times for one resident, did not adequately address significant weight loss and nutritional monitoring for another resident, and failed to ensure physician review of pharmacy recommendations for a third resident. These issues were discussed with facility leadership during the exit conference.
Violations (3)
Facility staff failed to change the administration times for the medication Voltaren gel per the physician's order for Resident #221.
Facility staff failed to follow Registered Dietician recommendations for weight monitoring and failed to ensure physician addressed weight loss for Resident #46.
Facility staff failed to ensure physician reviewed pharmacy recommendations regarding medication regimen for Resident #4.
Report Facts
Residents in survey sample: 21
Residents in survey sample: 23
Residents in survey sample: 21
Resident #46 weights: 102.8
Resident #46 weights: 118
Resident #46 weights: 120.1
Resident #46 weights: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration times, weight loss monitoring, and pharmacy review findings |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about Resident #46's eating habits |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about Resident #46's eating habits |
Inspection Report — Apr 15, 2021
Complaint Investigation
Date: Apr 15, 2021
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to follow physician's orders and other regulatory compliance issues at the facility.
Complaint Details
The complaint investigation found failures in following physician orders, medication storage, food service sanitation, QA meeting documentation, and infection control practices.
Findings
The facility failed to timely implement physician orders for a resident, safely store medications including expired drugs, maintain sanitary food service practices, provide evidence of quarterly QA meetings, and maintain an effective infection prevention and control program.
Violations (5)
Failure to ensure timely implementation of physician orders for head CT and medication Zyprexa for Resident #105.
Failure to safely store medications; expired medications found in medication room.
Failure to ensure serving pans were dry and clean and failure to date an opened package of dried pasta.
Failure to provide evidence that the facility QA committee met at least quarterly for the last two quarters of 2020.
Failure to maintain an effective infection prevention and control program; failure to perform hand hygiene during wound care for Resident #12.
Report Facts
Residents sampled: 16
Residents affected: 1
Residents affected: 1
Expired medications observed: 8
QA quarters missing evidence: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency for failure to perform hand hygiene during wound care |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding delayed physician orders and medication storage issues |
| Administrator | Facility Administrator | Informed of deficiencies during exit conferences |
| Dining Services Manager | Interviewed regarding food service sanitation deficiencies | |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control deficiency |
Inspection Report — Apr 7, 2019
Annual Inspection
Date: Apr 7, 2019
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident care, medication storage, infection prevention, and food safety.
Findings
The facility was found deficient in several areas including failure to follow physician orders for resident care (TED hose application), failure to secure a Foley catheter properly, unsecured medication storage, and multiple food safety and sanitation violations in the kitchen.
Violations (4)
Facility staff failed to ensure Resident #14 was wearing physician ordered TED hose.
Facility staff failed to ensure Resident #52's Foley catheter was secured with a leg strap.
Facility staff failed to securely store medication in one of two medication rooms; medication room door was found open and treatment cart unlocked.
Kitchen staff failed to prepare food in a clean and sanitary manner, including improper food temperature control, thawing raw chicken improperly in sink with food debris, use of personal drink cups in food prep area, moisture trapped in nested baking pans, unclean stove top and fire sprinkler faucets, trash and debris on sugar bin lid, and greasy slippery floors.
Report Facts
Residents in survey sample: 19
Temperature of hot cereal/grits: 130
Temperature of scrambled eggs: 130
Temperature of baked apples: 140
Required temperature for steam table foods: 145
Number of baking pans nested: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Spoke about Resident #14's TED hose order and observations |
| RN #1 | Registered Nurse | Confirmed Resident #52's Foley catheter should be secured with a strap |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation and food thawing procedures |
| Cook I | Cook | Observed thawing chicken improperly and planned to discard it |
4 CMS Surveys
CMS Survey — Aug 25, 2023
Aug 25, 2023
CMS Survey — Apr 8, 2019
Apr 8, 2019
CMS Survey — Apr 15, 2021
Apr 15, 2021
CMS Survey — Aug 25, 2023
Aug 25, 2023
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