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: April 14, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 renewal inspection was initiated on 4-13-2021 and concluded on 4/14/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 60. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, facility infection control plan, health care oversight, fire and health inspections and dietician oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on a review of staff records, the facility failed to ensure that new employees received at least 10 hours of training in cognitive impairments within the first 4 months of employment. EVIDENCE: 1. The record for staff person 2, hired on 10/7/2020, has documentation that the employee only received 3.5 hours of training in cognitive impairments within the first 4 months of their employment.
Plan of Correction:	Facility will comply with all mandatory training in cognitive impairment within the first four months of employment.
Standard #:	22VAC40-73-100-C-1
Description:	Based on a review of facility policy and procedures, the facility failed to ensure that their infection control plan addresses all required information. EVIDENCE: 1. A review of the facility infection control plan supports the the plan does not address the sanitation of rooms, including cleaning and disinfecting procedures, agents, and schedules or a facility staff health program.
Plan of Correction:	Facility will review and amend facility infection control policy to comply with 22VAC40-73
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that all new direct care staff received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff person 2, hired on 10/7/2020 did not contain documentation that the employee has received certification in first aid since their date of employment.
Plan of Correction:	Administrator or designee will review all staff records for compliance that each direct care staff team member will have First Aid within 60 days of employment.
Standard #:	22VAC40-73-440-B
Description:	Based on a review of staff training records, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed by qualified assessors. EVIDENCE: 1. The UAI dated 3/18/2021 in the record for resident 1 was completed and signed by staff person 5. Staff person 5's record did not contain any certification that the employee has completed private pay UAI training to be qualified to complete resident UAI's.
Plan of Correction:	Facility will ensure that UAI and completed by qualified assessors.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has a physician order dated 3/11/21 that indicates that the resident medications may be crushed and placed in food or drink of choice as directed by the MD. The ISP dated 3/18/21 in the record for resident 1 does not address this identified need. 2. The record for resident 2 has a physician order dated 3/22/21 for oxygen 2 liters/min via NC as needed for shortness of breath. The ISP dated 4/13/2021 in the record for resident 2 does not address the specifics of the oxygen use for resident 2 as it only has documentation that "oxygen will be kept at level as ordered by MD".
Plan of Correction:	Administrator or designee will review all resident charts to ensure that all needs are being addressed on the ISP
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to ensure that a criminal history report was obtained for each new employee on or prior to their 30th day of employment. EVIDENCE: 1. The record for staff person 6, hired on 2/5/2021, has a criminal history report that was not completed until 3/30/2021. 2. The record for staff person 7, hired on 7/20/2020, has a criminal history report that was not completed until 8/25/2020. 3. The record for staff person 8, hired on 9/18/2020, has a criminal history report that was not completed until 10/26/2020.
Plan of Correction:	Facility will obtain all criminal history reports for each employee on or before the 30th day of employment.