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: March 12, 2024

Complaint Related: No

Areas Reviewed:

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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/12/2024 8:30am until 4:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/30/2024 regarding allegations in the area(s) of: Personnel and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Personnel A violation notice was issued; any violation(s) not related to the self-report 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 #:	22VAC40-73-130-A
Description:	Based on resident record review and staff interviews, the facility failed to ensure that mandated reporters under 63.2-1606 of the Code of Virginia reported suspected abuse, neglect or exploitation of residents in accordance with that section. EVIDENCE: 1. The record for resident 1 has an incident report that is dated 01/30/2024. The incident report indicates that a staff person may have hit resident 1 but only a part of the incident was observed. In an interview with staff person 1 conducted on 03/12/2024, staff person 1 expressed that staff person 2 had observed staff person 3 smack resident 1 on the back of the head. Staff person 1 also expressed that during their investigation they had concluded that the incident had occurred and that staff person 3 was terminated from employment with the facility and a complaint was filed with the Department of Health Professions by staff person 1. 2. As of 03/12/2024, the day of on-site inspection, it was noted that the facility has not reported the incident to the local adult protective services agency.
Plan of Correction:	Administrator/designee will ensure education is provided to all staff on mandated reporting, any report of suspected abuse neglect or exploitation of residents will be reported to the appropriate agencies.