VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Liberty Ridge Memory Support - Pearls of Life
107 Monica Blvd.
Lynchburg, VA 24502
(434) 237-2268

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Aug. 18, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 8/17/20 and concluded on 11/18/20. A complaint was received by the department regarding allegations in the areas of personnel, resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on a review of resident records, the facility to report any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. EVIDENCE: 1. The record for resident 2 has documentation of the resident sustaining a fall with injury that required emergency room care on 8/10/2020. The facility did not report this incident to the licensing office. 2. The record for resident 3 has documentation of bruising of an unknown origin to the residents upper and lower right and left arms on 8/17/2020. The facility did not report this incident to the licensing office. 3. The record for resident 9 has documentation of the resident sustaining a fall on 5/25/2020 and 6/23/2020 which required emergency room care. The facility did not report this incident to the licensing office. 4. The record for resident 10 has documentation of the resident sustaining a fall on 6/20/20 requiring emergency room care. The facility did not report this incident to the licensing office.
Plan of Correction:	The facility will report any major incidents that have negatively affected or threaten the life, safety, or welfare of any residents within 24 hours of the incident.
Standard #:	22VAC40-73-200-A
Complaint related:	Yes
Description:	Based on a review of staff records and interviews with staff, the facility failed to ensure that employees hired as direct care aides met the age requirements for this position. EVIDENCE: 1. The record for staff person 1, hired on 3/17/2020 as the front desk concierge, has documentation that the employee received direct care training on 7/27/20 through 7/31/20. The record has a direct care training certificate for completion of the training dated 7/31/20. The facility employee schedule for for July 2020 has documentation of staff person 1 being "in training " as a direct care aide on 7/27/20 through 7/31/20 and the August 2020 employee schedule has staff person 1 working the day shift as a direct care aide on 8/3/20, 8/4/20, 8/17/20, 8/18/20 and 8/19/20. The record for staff person 1 has documentation of the employees birthday as 12/17/2003, which makes this employee under the age of 18 and unable to be employed as a direct care aide at this time.
Plan of Correction:	Facility will maintain staff members over the age of 18 as a direct care. This staff member completed all the training and is currently enrolled in a CNA class through her school as her future is in nursing
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to update residents individualized service plans (ISPs) when a change in the residents condition occurred. EVIDENCE: 1. The ISP dated 2/25/20 in the record for resident 2 has documentation dated 2/26/20 that the resident is a risk for falls. The record has documentation of the resident sustaining falls on 7/4/20, 7/6/20, 7/7/20, 8/10/20 which required EMS services and 8/17/20 which also required EMS services. The ISP dated 2/25/20 does not include any attaional information/intervention put in place for fall prevention for this resident.
Plan of Correction:	During a change in a residents condition the ISP will be updated to reflect the change