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 11, 2020

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 22VAC40-80 COMPLAINT INVESTIGATION.

Technical Assistance:

The licensing inspector and Administrator had a discussion regarding medication administration records in regards to standard 680 I.

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 complaint inspection was initiated on 06/11/2020 and concluded on 6/25/2020. A complaint was received by the department regarding allegations in the areas of residents residing in the facility who need a higher level of care and staff not wearing the correct Personal Protective Equipment (PPE). The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-70-C
Complaint related:	No
Description:	Based on document review, the facility failed to submit a complete written report of an incident that negatively affected or threatened the life, health, safety or welfare of a resident to the regional licensing office within seven days from the date of the incident. EVIDENCE: 1. On 05/07/2020, staff 2 provided a written report of an incident for resident 8; ?Resident was flipped backwards in chair on kitchen floor?. The report did not include the following required information about the incident: actions taken in response to the incident, actions to prevent recurrence of the incident, if applicable, and name of staff person in charge at the time of the incident.
Plan of Correction:	Written report covering fall incident that negatively affected or threatened the life, health, safety or welfare of a resident on 5/07/2020, will be finalized for regional licensing office. We did not send a report for this particular incident as we were under the impression that if the person was not sent to the hospital that it was not necessary. The family rep as well as facility's Nurse were notified. It scared the resident more than it actually hurt her. The resident was monitored for the rest of the night. We will monitor this type of issue better in the future.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care. EVIDENCE: 1. The licensing office was notified on 04/18/2020 that resident 1 was found lying in the floor by staff 1, 911 was called, and resident 1 was taken to the ER. 2. The Uniform Assessment Instrument (UAI), dated 12/19/2019, assessed resident 1 as assisted living level of care. 3. The record for resident 1 did not contain A ?Fall Risk Assessment? for the fall on 04/18/2020. 4. Interview with staff 2 revealed that the fall risk rating had not been updated.
Plan of Correction:	Fall Risk Assessment for fall on 4/18/2020 for Resident 1 has been updated. Fall Risk rating will be monitored more closely in the future and updated as needed for residents after a fall who meet the criteria for assisted living care
Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to have documentation of 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. The Uniform Assessment Instrument (UAI), dated 12/19/2019, assessed resident 1 as assisted living level of care. 2. The record for resident 1 contained ?Fall Risk Assessment? forms that showed the resident fell on the following dates: 03/18/2020, 03/22/2020, 04/22/2020, 05/04/2020, 05/05/2020, 05/10/2020, 05/12/2020, 05/17/2020, 05/19/2020, 05/27/2020 and 06/08/2020. 3. The record for resident 1 did not contain updated documentation of interventions that were initiated to prevent or reduce risk of subsequent falls. 4. The individualized service plan (ISP) for resident 1, dated 12/19/2019, shows identified need, ?FALL RISK? and description of services to be provided, ?Assist resident with ADLs/IADLs, balance issues, fear of falling, coordination as well as monitoring use of walker. Monitor resident and environment?.
Plan of Correction:	Documentation follows for Resident 1 of interventions determined and initiated to prevent or reduce risk of subsequent falls after Resident 1 fell: - put shoes on immediately upon getting out of bed - advise Resident 1 to pay closer attention when moving about - advise Resident 1 to ALWAYS use assistive device - monitor Resident EVERY hour for assistive device and environment
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to complete the Uniform Assessment Instrument (UAI) as required. EVIDENCE: 1. The private pay UAI for resident 1, dated 12/19/2019, showed the resident needs help with walking but did not indicate what kind of assistance resident 1 needs with walking. 2. The private pay UAI for resident 2, dated 01/21/2020, showed the resident needs mechanical and physical assistance with dressing. The individualized service plan (ISP), dated 01/21/2020, showed that resident 2 needs physical assistance with dressing. Interview with staff 2 revealed that the ISP is correct, and the UAI assessment in is incorrect. 3. The private pay UAI for resident 3, dated 02/13/2020, showed the resident needs help with transferring but did not indicate what kind of assistance resident 3 needs with transferring. 4. The private pay UAI for resident 7, dated 09/11/2019, showed the resident needs physical assistance with bathing. The ISP, dated 09/11/2019, showed the resident needs ?safety bars/supervision? with bathing. Interview with staff 2 revealed both were incorrect.
Plan of Correction:	In the future, better monitoring of responses on the private pay UAI will be done as well as the ISPs. 1. Showed needs help for walking on UAI but failed to show what kind - Corrected to reflect Mechanical Help Only. 2. Inadvertently showed Mechanical & Human Help for dressing for Resident 2 - Corrected to reflect Human Help Only 3. Showed needs help for transferring but failed to show what kind - Corrected to reflect Mechanical Help Only 4. Inadvertently showed Human Help physical assistance only with bathing - Corrected to show Mechanical Help and physical assistance for bathing ance
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure residents? individualized service plan (ISP) included a description of all identified needs and who will provide services. EVIDENCE: 1. The private pay uniform assessment instrument (UAI) for resident 3, dated 02/13/2020, showed the resident needs mechanical and physical assistance with dressing. The ISP, dated 02/13/2020, for resident 3 showed the resident needs physical assistance with dressing. Upon questioning, staff 2 revealed that the UAI is correct and the ISP is incorrect. 2. The ISP, dated 12/19/2019, for resident 1 showed service needed ?PT/OT/ST?, and persons who will provide services ?Agency of Choice?. The ISP did not show the services were provided by Seven Hills Home Health. The record for resident 1 contained physical therapy notes from Seven Hills Home Health and showed the resident received physical therapy services from 01/27/2020 ? 02/24/2020. Interview with staff 2 revealed that physical therapy services were the only services received by resident 1 from 01/27/2020 ? 02/24/2020 and they were discontinued in February 2020. 3. The private pay UAI for resident 4, dated 07/19/2019, showed the resident needs mechanical and physical assistance with bathing. The ISP, dated 04/02/2020, for resident 4 showed the resident needs mechanical and ?standby supervision with bathing?. Interview with staff 2 revealed that the UAI is correct and the ISP is incorrect. 4. The ISP for resident 4, dated 04/02/2020, contained ?description of needs and date identified ? 04/02/2020 PT?. ?Persons who will provide services ? agency of choice?. Interview with staff 2 revealed that resident 4 received physical therapy from Seven Hills Home Health although this was not included on the ISP.
Plan of Correction:	ISPS will be monitored more closely in the future. 1. Corrected ISP for mechanical and physical assistance with dressing for Resident 3 2. Correction to ISP will be made, showing PT/OT/ST for Resident 1, including the Agency that provided the services 3. Corrected ISP for mechanical and physical assistance with bathing for Resident 4 4. Correction to ISP will be made, showing the Agency that provided the services for Resident 4
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated as needed as the condition of the resident changes. EVIDENCE: 1. The ISP, dated 09/24/2019, for resident 9 shows a description of needs ?SELF-ADMINISTERED MEDICATIONS?, ?may keep following meds in apartment: ProAir HFA 108 (90 Base) and MCG/ACT Aerosol Soln Inhaler Medications will be ordered and monitored? and that ?Resident will have medications in room when needed? This ISP was not updated to show that these medications were discontinued per a signed physician?s order, dated 12/02/2019. 2. The record for resident 5 contained physical therapy notes from Seven Hills Home Health and showed the resident received physical therapy from 05/13/2020 ? 06/18/2020. These services were not included on the resident?s ISP dated 04/02/2020.
Plan of Correction:	ISPs will be monitored more closely in the future ISP for Resident 9 will be updated, reflecting discontinued medications (ProAir HFA 108 (90 Base) and MCG/ACT Aerosol Soln Inhaler per a signed physician's order 12/02/19 ISP for Resident 5 will be updated, reflecting Physical Therapy notes from Seven Hills Home Health from 5/13/2020 - 6/18/2020
Standard #:	22VAC40-73-580-F
Complaint related:	No
Description:	Based on resident record review, the facility failed to notify resident?s attending physician when a significant weight loss of 5.0% in one month was identified. EVIDENCE: 1. ?YEARLY WEIGHTS? for resident 4 showed the resident weighed 163 lbs in March 2020, 153 lbs in April 2020 and 149 lbs. in May 2020. The record for resident 4 did not contain documentation that the resident?s attending physician was notified of the weight loss each of these months.
Plan of Correction:	In the future, the WEIGHT SHEETS will be highlighted and sent to Assisted Living Administrator for monitoring before sending to Nurse