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: Sept. 18, 2023

Complaint Related: Yes

Areas Reviewed:

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

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: 09/18/2023 11:00am until 1:00pm 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 regarding allegations in the area(s) of: Personnel, Staffing and resident care and related services Number of residents present at the facility at the beginning of the inspection: 59 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident care and related services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to ensure that a fall risk rating was completed when a resident who is assessed as assisted living level of care falls. EVIDENCE: 1. The record for resident 1, who is assessed as assisted as assisted living level of care, has documentation that the resident had an unwitnessed a fall on 09/09/2023 that required a call to emergency medical services. The record for resident 1 does not have documentation that a fall risk assessment was completed after the fall on 09/09/2023.
Plan of Correction:	Facility Administrator or Designee will ensure that a fall risk rating is completed after a fall. Administrator/designee will routinely audit for completion.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to ensure that individualized service plans (ISP) were updated as needed for a significant change in a residents condition. EVIDENCE: 1. The record for resident 1 has documentation of the resident falling on 06/28/2023, 08/25/2023 and 09/09/2023. A fall risk rating completed on 08/26/2023 has documentation that resident 1 is a high risk for falls. The ISP last updated on 09/15/2023 does not have documentation to address the identified need of a high fall risk for resident 1.
Plan of Correction:	Facility Administrator or designee will ensure resident ISP addresses resident needs. Administrator/designee will routinely audit ISP?s.