Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Our Lady Of The Valley
ROANOKE, VA · 70 certified beds · Last Life Safety survey August 25, 2023
CMS Certification Number 495357 · first certified October 2001
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Our Lady of the Valley (650 N. Jefferson St). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within VA
23 citations — more than 88% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: March 2026 to March 2027. This facility’s last Life Safety survey was August 2023. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 8, 2019 | 5 |
| April 15, 2021 | 16 |
| August 25, 2023 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2021-04-15 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2021-04-15 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2021-04-15 |
| E-0007 | Address patient/client population and determine types of services needed. | 1 | 2021-04-15 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2021-04-15 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2021-04-15 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2021-04-15 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2021-04-15 |
What the citations cover
- Emergency Preparedness Deficiencies 6
- Smoke Deficiencies 5
- Egress Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 6 |
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 25, 2023 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 28, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (March 28, 2024) |
April 15, 2021 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 25, 2021) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (May 25, 2021) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (May 25, 2021) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (May 25, 2021) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (May 25, 2021) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (May 25, 2021) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 15, 2021) |
April 8, 2019 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 20, 2019) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (June 20, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 20, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 20, 2019) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 20, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.