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: May 23, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/23/2022 8:30am until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/20/2022 regarding allegations in the area(s) of: resident care and related services, staffing and supervision and additional requirements for facilities that care for residents with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. 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. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	No
Description:	Based on a review of the facility employee schedule, daily assignment sheets and interview with staff, the facility failed to ensure that during the night hours when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents were in the building. EVIDENCE: 1. In an interview with staff persons 1 and 2 on the day of inspection it was expressed that the facility census has been between 50 and 56 from 04/01/2022 to 05/23/2022, which would require that at least 6 direct care staff be on-site during the night hours. The facility daily assignment sheets for April and May 2022 has 5 or less direct care staff scheduled on-site during the night hours for the following days; 04/01/2022 through 04/04/2022, 04/10/2022, 04/15/2022, 04/22/2022, 04/28/2022 through 04/30/2022, 05/02/2022, 05/13/2022, 05/14/2022, 05/16/2022, 05/20/2022 through 05/22/2022.
Plan of Correction:	Administrator or designee will ensure that during the night hours, when more than 40 residents are present, at least 4 direct care members plus at least one more direct care members for every additional 10 residents or portion thereof.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to ensure that a fall risk rating was completed when a fall occurred for residents who are assessed as assisted living level of care. EVIDENCE: 1. The record for resident 1 has documentation of the resident falling on 04/02/2022. Documentation of a fall risk rating being completed for this fall was not noted in the record for resident 1.
Plan of Correction:	Administrator or designee will ensure that the fall risk assessment shall be reviewed and updated annually, when the condition of the resident changes or after a fall.