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: June 2, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/2/2020 and concluded on 6/3/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 48. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, facility employee schedule, fire and health department inspections, fire drill logs, facility health care oversight and the most recent dietitian report submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received 18 hours of training annually. EVIDENCE: 1. The record for staff person 1, employed on 8/29/2016, has documentation that the employee only received 14.5 of the required 18 hours of annual training from the time period of August 2018 through August 2019.
Plan of Correction:	The Administrator found 2 additional hours of training for this employee. The Administrator will review all staff training records to ensure that all direct care staff receive the required number of training hours annually.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure that physical examinations were completed as required prior to a residents admission. EVIDENCE: 1. The physical examination dated 7/9/2019 in the record for resident 1 is incomplete as it lacks a statement that specifies whether the individual is or is not capable of self-administering medication. 2. The physical examination dated 3/26/2020 in the record for resident 3 is incomplete as it lacks a statement that specifies whether the individual is or is not capable of self-administering medication.
Plan of Correction:	The Administrator will submit to the residents 1 and 3's physicians to update their physical examinations. The Administrator has reviewed admission packets to ensure that the updated physical examination forms are used for all new admissions.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has a fall risk assessment completed on 7/18/2019 that identifies the resident as a fall risk. The comprehensive ISP dated 7/25/2019 does not address this identified need. 2. The record for resident 2 has a fall risk assessment completed on 4/8/2020 that identifies the resident as a fall risk. The record also has documentation of home health services for wound care. A phone conversation with staff person 4 on 6/3/2020 expressed that resident 2 received home health services and physical therapy services from 2/5/2020 through 5/27/2020. The comprehensive ISP dated 8/21/2019 in the record for resident 2 did not address these identified needs. 3. The record for resident 3 has a fall risk assessment completed on 3/31/2020 that identifies the resident as a fall risk. The comprehensive ISP dated 4/3/2020 does not address this identified need.
Plan of Correction:	The Administrator will update resident 1, 2 and 3's ISP's to include all identified needs and will conduct audits of all ISP's to ensure that identified needs are addressed.
Standard #:	22VAC40-73-450-D
Description:	Based on review of resident records, the facility failed to ensure that the services provided by both, the assisted living facility and the licensed hospice organization, were included on the individualized service plan (ISP). EVIDENCE: 1. The record for resident 3 shows the resident is receiving hospice services. The resident?s comprehensive ISP, dated 4/3/2020, indicates the resident is receiving hospice services, but does not include the services provided by the hospice organization.
Plan of Correction:	The Administrator will update resident 3's ISP to include details of all hospice services being provided to the resident.
Standard #:	22VAC40-73-680-K
Description:	Based on a review of resident records, the facility failed to ensure that orders for PRN medications contained the symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. The May 2020 MAR for resident 2 has a physician order for Narcan 4mg nasal spray to be used for an overdose, but the order does not contain the symptoms that indicate the use of the medication, the time frames for the medication to be administered or directions on what to do if symptoms persist.
Plan of Correction:	The Administrator/DON has contacted the residents physician to request the medication be discontinued or detailed instructions provided as to how to properly administer the medication.