VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Valley View Retirement Community
1213 Long Meadows Drive
Lynchburg, VA 24502
(434) 237-3009

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 24, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS

Comments:

On 10/24/2019 one inspector conducted an investigation (12:10pm to 3:05pm) regarding the facility not reporting incidents to licensing, falsifying records, and not having orders to administer medications. Three resident files were reviewed, staff were interviewed, and residents were interviewed. There is no evidence to support the allegations in the complaint; it is not valid. During the course of the investigation two violations were noted and they are on the violation notice. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident record review and interviews, the facility failed to have annual fall risk ratings done on residents, and fall risk ratings after residents fell. EVIDENCE: 1. The most recent fall risk rating for resident 1 is dated 4/11/2018. This was noted on 10/24/2019. 2. The most recent fall risk rating for resident 2 is dated 4/11/2018. This was noted on 10/24/2019. Resident 2, in an interview, said she thinks she fell sometime this month, but isn't sure. 3. The most recent fall risk rating for resident 3 is dated 4/25/2018. This was noted on 10/24/2019. Resident 2, in an interview, said she fill once this month, and her roommate, resident 3, falls all of the time. Staff has to help resident 3 get up.
Plan of Correction:	The Fall Risk Assessment Sheet is up-to-date on Resident 1. Resident 1 has no evidence of falling in the time the Resident has been at Valley View. Resident 1's annual Assessment information has been entered on the Fall Risk Assessment. The Fall Risk Assessment Sheet is up-to-date on Resident 2. Resident 2 has fallen twice since 4/11/2018. Both falls have been entered on the Assessment sheet along with the "intervention" information. The Fall Risk Assessment Sheet is up-to-date on Resident 3. Resident 3 has fallen 7 times since 4/25/2018. All 7 of the falls have been entered on the Assessment sheet along with the "intervention" information. Steps to Correct the Noncompliance with the Standard(s): Fall Risk assessment will be done annually at the time of ISP assessment, when the condition of the resident changes, and after a fall. Measures to prevent the noncompliance from occurring again: We will be working on our files, bringing them up to date in the month of November and December. Person(s) responsible for implementing each step and/or monitoring any preventive measures: Staff 2, LPN/RCC; staff 1, AL Administrator; staff 3, AL Administrative Assistant; and, staff 4, Asst. Team Leader-CNA/RMA
Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on resident record review and interviews, the facility failed to have documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls for residents who meet the criteria for assisted living care after they fell. EVIDENCE: 1. Resident 3 stated in an interview that she thinks she fell, and her roommate, resident 2, stated that resident 3 falls frequently. The file for resident 3 lacks documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. 2. Resident 2 stated in an interview that she fill once recently. The file for resident 2 lacks documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	Analysis: Resident 3 needs to pay closer attention and take her time. When she slides out of her chair, she needs to be careful and use the arms of her chair and when she slides off her bed, she needs to be careful and pay closer attention. Steps to Correct the Noncompliance with the Standard(s): Fall Risk assessment will be done annually at the time of ISP assessment, when the condition of the resident changes, and after a fall. Measures to prevent the noncompliance from occurring again: We will be working on our files, bringing them up to date in the month of November and December. Person(s) responsible for implementing each step and/or monitoring any preventive measures: Staff 2, LPN/RCC; staff 1, AL Administrator; staff 3, AL Administrative Assistant; and, staff 4, Asst. Team Leader-CNA/RMA