VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady Of Peace
751 Hillsdale Drive
Charlottesville, VA 22901
(434) 973-1155

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Nov. 1, 2022

Complaint Related: No

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: 11/01/2022 approximate times of 10:54 a.m. ? 4:22p.m 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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: 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. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-B
Description:	Based on the review of facility records the facility failed to ensure that a risk assessment for tuberculosis shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident #1-Documented date of admission 02/21/2018. The most recent TB assessment that was submitted for the inspector?s review is dated 02/13/2021. Resident #2-Documented date of admission 09/01/2020. The most recent TB assessment that was submitted for the inspector?s review is dated 09/01/2021.
Plan of Correction:	FACILITY'S RESPONSE: "All resident records were audited for updated TB assessments and those identified as incomplete were completed. DON or designee will complete TB assessments annually. Administrator or designee will complete an audit quarterly and report findings to QA committee for current quarter."
Standard #:	22VAC40-73-325-B
Description:	Based on the review of facility records the facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating is completed. Evidence: Resident #3: Documented date of admission 09/14/2022 The resident?s comprehensive ISP is dated 10/26/2022. Upon request the facility did not submit for the inspector?s review documented evidence that a fall risk rating was completed by the time or since the resident?s comprehensive ISP was developed.
Plan of Correction:	All resident records were audited for completed fall risk assessments and those identified as incomplete were completed. ADON or designee will complete fall risk assessments per facility policy including by the time the comprehensive ISP is complete. Administrator or designee will complete fall risk assessment audit in current quarter and report findings to QA committee."
Standard #:	22VAC40-73-430-H-1
Description:	Based on the review of facility records the facility failed to ensure that a copy of the written statement of discharge was maintained in the resident's record. Evidence: Resident #10 During interviews facility staff confirmed that the resident was no longer in care but did not submit upon request documented evidence that a discharge statement was maintained.
Plan of Correction:	Administrator or designated representative will be responsible for issuing the written statement of discharge and filing it in the resident?s business file. Executive director or designee will audit discharged resident files for documentation by 11/18/2022. Executive director or designee will conduct audit of discharged resident files in next quarter and report findings to QA committe
Standard #:	22VAC40-73-580-A
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: Upon request the facility did not submit for the inspector?s review that an annual health inspection was conducted at the facility
Plan of Correction:	FACILITY'S RESPONSE: "Last health department inspection was 09/03/2021. Health Department visit scheduled for 11/16/2022. Executive director or designee will request annual health inspection as needed."
Standard #:	22VAC40-73-620-B
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that upon receipt of recommendations noted in subdivision 3 of this subsection, the administrator, dietitian, or nutritionist must report them to the resident's physician. Documentation of the report shall be maintained in the resident's record. Upon request the facility did not submit for the inspector?s review documented evidence that the physician?s for the residents identified in the 09/01/2022 dietician report were made aware of the dietician?s recommendation and what action was taken in response to the recommendations
Plan of Correction:	FACILITY'S RESPONSE: "Dietitian recommendations from 09/01/22 report were reviewed, and physicians were notified of findings as indicated. Administrator or designee will complete an audit of Registered Dietitian recommendations and actions documented in resident records in next quarter and report findings to QA committee."
Standard #:	22VAC40-73-680-C
Description:	Based on the review of facility records and observation the facility failed to ensure that medications are administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. Evidence: Resident #11 Observation of the morning medication administration pass with facility staff #5 revealed that on 11/01/2022 the resident was not administered the 9:00a.m medications until the approximate time of 10:51 a.m.
Plan of Correction:	FACILITY'S RESPONSE: "Education provided to RMA on medication administration on 11/01/2022. All RMAs and Nurses will be educated on proper medication administration by 11/30/2022. Report of medication administration will be reviewed per policy to ensure compliance. Med pass audits will be conducted on all Nurses and RMAs by 11/30/2022. Findings will be reported to QA committee by ADON or designee."
Standard #:	22VAC40-73-690-E
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that upon receipt the resident?s attending physician was informed of the recommendation of any concerns or problems and document the notification. Evidence: Upon request the facility did not submit for the inspector?s review documented evidence that the physician?s for the residents identified in the 09/21-22/2022 medication review report were made aware of the pharmacist recommendations and what action was taken in response to the recommendations.
Plan of Correction:	Review of submitted document given to inspector noted to be Pharmacy QA Nurse Audit and not Pharmacist Recommendation Report requiring physician notification. FACILITY'S RESPONSE: "Administrator and ADON reviewed most recent Pharmacist Recommendation Report and audited resident charts. All recommendations were followed up with the residents? physicians and resolutions were documented as appropriate. Administrator or designee will continue to review Pharmacist Recommendation Report and audit resident charts in next quarter to ensure recommendations and actions are followed up as needed. Pharmacist will also continue to follow up as appropriate quarterly."
Standard #:	22VAC40-73-940-A
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that an assisted living facility complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: Upon request the facility did not submit for the inspector?s review that an annual fire inspection was conducted at the facility.
Plan of Correction:	FACILITY'S RESPONSE: "Last fire inspection was 04/01/2021. Fire Department visit scheduled for 11/10/2022. Executive director or designee will request annual inspections as needed."