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. 4, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 10/4/2019 one inspector conducted a complaint investigation regarding residents falling, no RN on one of the floors of the ALF, weight loss, and denying residents' their medications. Resident records show numerous falls have occured, without notifying licensing. There is no requirement to have a nurse employed or on duty at an ALF, and no evidence that medications were not given as ordered. Based on the evidence regarding falls, the complaint is valid. One other violation was found, and that is cited in 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on review of resident records, the facility failed to report to the regional licensing office within 24 hours on any major incident that has negatively affected or that threatens the life, health , safety, or welfare of any resident. EVIDENCE: 1. Falls Investigation Worksheets in the file for resident 1 show that she fell on 9/17/2019 and was sent to the hospital the next day because of the fall. The licensing office was not notified. 2. Falls Investigation Worksheets for resident 3 show she fell approximately 20 times between 12/21/2018 and 7/22/2019. The licensing office was not notified, despite at least two of the falls resulted in the resident sent to the hospital. 3. A Falls Investigation Worksheet in the file for resident 2 show a fall occurred on 8/3/2019, and a handwritten note shows the resident also fell on 9/13/2019, which resulted in her being sent to the hospital. These incidents were not reported to the licensing office. 4. A Falls Investigation Worksheet in the file for resident 5 shows she had a fall on 7/13/2019 which resulted in the resident being sent to the hospital. The licensing office was not notified.
Plan of Correction:	Most of the residents listed have passed away and are no longer with us. However, correction of the issues listed were rectified immediately 10/05/19, with regard to the faxing of the licensing office and the reporting falls ending in hospitalization of a resident. Reviewing balance of the residents' files for "Fall Risk Assessments" should be accomplished by 2/21/2020 Measures to prevent noncompliance are being reviewed as follows: 1. Inservice on "Fall Worksheets" 1/15/2020 2. Inservice on "Incident Reports" 1/15/2020 3. Inservice with personnel to fax reports to DSS (MedAide 4/3 on duty) 1/15/2020 4. Inservice with personnel responsible for monitoring 1/16/2020
Standard #:	22VAC40-73-430-H-2
Complaint related:	No
Description:	Based on review of resident records, the facility failed to have a copy of a discharge statement in a resident's file. EVIDENCE: 1. Resident 4 was sent out to a hospital on 8/28/2019 and passed away at the hospital on 8/30/2019. The record for resident 4 did not have a copy of the discharge statement in it.
Plan of Correction:	The discharge statement was taken care of for Resident 4 on 10/05/2019. Measures to prevent noncompliance were reviewed and the "Discharge Statement" will be provided on or before the date of the discharge.