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: April 19, 2021

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.

Technical Assistance:

To ensure the facility had a thorough understanding of standards, the LI and the Community Director had a discussion regarding standard 680 E.

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 04/15/2021 and concluded on 04/23/2021. The Community Director was contacted by telephone to initiate the inspection. The Community Director reported that the current census was 31. The inspector emailed the Community Director a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, recent health care oversight, recent health department inspection, past three fire drills, recent fire inspection, recent dietitian review, and recent medication review submitted by the facility to ensure documentation was complete. To ensure the facility had a thorough understanding of standards, the LI, the Community Director and the Resident Care Coordinator had a discussion regarding standards 270, 450 A and 450 C. 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 #:	22VAC40-73-100-C-1
Description:	Based on document review, the facility failed to insure that the infection control program included all required components. EVIDENCE: 1. The facility infection control program provided to the licensing inspector for review does not contain the following requirements: determination of whether prospective or returning residents have acute infectious disease and use of appropriate measures to prevent disease transmission, use of safe injection practices and other procedures where the potential for exposure to blood or body fluids exists, the handling storing, processing, and transporting or linens, supplies and equipment in a manner that prevents the spread of infection, the sanitation of rooms schedules, maintenance of an effective pest control program, product specific instructions for use of cleaning and disinfecting agents (e.g., dilution, contact time, and management of accidental exposures) and initial training as specified in 22VAC40-73-120 C 4 and annual training of volunteers in infection prevention methods, as applicable to job responsibilities and as required by 22VAC40-73-210 F.
Plan of Correction:	The following requirements are not contained in the facility infection control program: 1a. Determination of whether prospective or returning residents have acute infectious disease and use of appropriate measures to prevent disease transmission; use of safe injection practices and other procedures where the potential for exposure to blood or or body fluids exists; the handling, storing, processing, and transporting of linens, supplies and equipment in a manner that prevents the spread of infection; the sanitation of room schedules; maintenance of an effective pest control program; product specific instructions for use of cleaning and disinfecting agents (e.g. dilution, contact time, and management accidental exposures) and initial training as specified in 22VAC40-73-120 C 4 and annual training of volunteers in infection prevention methods, as applicable to job responsibilities and as required by 22VAC40-73-210F.
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review and staff interview, the facility, which accepts or has in care, residents who are or who may be aggressive, failed to ensure that direct care staff received the required minimum training prior to being involved in the care of such residents and annually. EVIDENCE: 1. The record for staff 1, date of hire 02/27/2020, contained documentation that staff 1 had ?Dementia Care: Aggressive Behaviors? training provided by staff 5 on 02/27/2020; however this training did not contain demonstration and practical experience in self-protection. 2. The record for staff 2, date of hire 07/27/2002, contained documentation that staff 2 had ?Advanced Dementia: Responding Positively to Disruptive Behavior 1 & 2? and ?Personality & Behavior Problems in the Aged? training provided by staff 5 on 07/23/2020 for the training year 07/27/2019 through 07/26/2020; however these trainings did not contain demonstration and practical experience in self-protection. 3. The record for staff 3, date of hire 08/18/2003, contained documentation that staff 3 had ?Disruptive Behavior: Do You Really Know Your Resident?? and ?Advanced Dementia: Understanding Disruptive Behavior? training provided by staff 5 on 08/14/2020 for the training year 08/18/2019 through 08/17/2020; however these trainings did not contain demonstration and practical experience in self-protection. 4. Interview with staff 4 confirmed that there was no demonstration and practical experience in self-protection training.
Plan of Correction:	Staff 1.2, 3 - No demonstration and practical experience in self-protection training Annual training with demonstration and practical experience in self-protection training to be given to necessary staff in Assisted Living
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to ensure that the fall risk rating was reviewed and updated annually for residents who meet the criteria for assisted living care. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident 2, dated 02/15/2021, assessed resident 2 as assisted living level of care. The most recent fall risk rating for resident 2 was documented on 02/13/2020. 2. The UAI for resident 3, dated 07/22/2020, assessed resident 3 as assisted living level of care. The most recent fall risk rating for resident 3 was documented on 10/06/2019.
Plan of Correction:	Reassess fall risk rating for Resident 2 & 3. The fall risk rating will be reassessed in the future when the UAI is annually reassessed for the ISP
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure residents? individualized service plans (ISP) included all required components and were completed within 30 days after admission. EVIDENCE: 1. Resident 1 was admitted to the facility on 01/08/2021. Interview with staff 5 revealed that the ISP in the resident?s record, signed on 12/01/2020, was the comprehensive ISP for resident 1. The comprehensive ISP was not completed within 30 days after admission. 2. The record for resident 1 has a fall risk rating completed on 12/18/2020 that identifies the resident as a fall risk. The comprehensive ISP, dated 12/01/2020, does not address this identified need. 3. The most recent ISP for resident 2, dated 02/15/2021, showed the resident receives ?PT As ordered by MD through outside agency? and persons who will provide services ?Agency of Choice?. The record for resident 2 contained documentation that the resident was admitted to physical therapy on 03/08/2021. The ISP did not include a written description of what services are provided and who will provide them. 4. The uniform assessment instrument (UAI) for resident 3, dated 07/22/2020, showed that the resident has bladder incontinence weekly or more. The ISP does not address bladder incontinence. Interview with staff 5 revealed that the UAI is correct.
Plan of Correction:	Resident 1's comprehensive ISP was 1/08/21. The date of 12/01/20 was inadvertently left on the ISP when I did another resident previous to Resident 1. Correction of date will be done Resident 1's comprehensive ISP was 1/08/21. Please see 1st paragraph above this paragraph. The comprehensive ISP will be corrected to show the identified need of fall risk. Resident 2's PT documentation did not include a written description of services provided and who will provide them. This information will be added to the ISP Resident 3's ISP will be corrected 7/22/2020 to reflect the bladder incontinence.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physicians or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, conditions or specific indications for administering each drug. EVIDENCE: 1. The physician?s order for resident 1, dated 12/21/2020, does not include the diagnosis, condition or specific indications for administering the following prescribed medications: Albuterol sulfate 2.5mg/3 ml, Aspirin 81 MG, Cyanocobalamin 1,000 MCG, Hydroxyurea 500 MG, Imodium A-D 2 MG, and Vitamin D2 1,250 MCG. The physician?s order for resident 1, dated 04/05/2021, showed ?Cephalexin 500 mg Capsules 2 capsules by mouth twice a day for 7 days? and ?Moisturizing cream apply on both legs twice a day?. The physician?s order for resident 1, dated 04/14/2021, showed ?Citalopram 10 mg Tablets 1 Tablet daily in the morning?. Neither of these orders contain the diagnosis, condition or specific indications for administering the medications. 2. The physician?s order for resident 2, dated 11/04/2020, showed ?Diclofenac 1% topical gel (100 GM Tube(s)) Apply 2 grams to the affected area(s) by topical route 2 times per day?. The physician?s order, dated 03/12/2021, showed ?Tizanidine 4 MG tablet Take 1 Tablet daily at bedtime as needed?. Neither of these orders contain the diagnosis, condition or specific indications for administering the medications. 3. The physician's order for resident 3, dated 03/10/2021, showed "Aricept 10 MG Oral Tablet 2 tab oral daily". The order does not contain the diagnosis, condition or specific indications for administering the medication.
Plan of Correction:	1** Physician's order for resident 1, dated 12/21/20 requires the diagnosis, condition or specific indications for administering the following medications: Albuterol sulfate 2.5mg/3ml, Aspirin 81mg, Cyanocobalmin 1,000mcg, Hydroxyurea 500 mg, Imodium A-D 2 mg, and Vitamin D2 1,250mcg *Physician's order for resident 1, dated 4/05/21, requires the "Cephanlexin 500 mg Capsules, 2 capsules by mouth twice daily for 7 days" and "Moisturizing cream apply on both legs twice a day". *Physician's order for resident 1, dated 4/14/21, showed "Citalopram 10 mg Tablets, 1 tab daily in the morning". Both order require the diagnosis, condition or specific indications for administering the medications. 2**Physician's order for resident 2, dated 11/04/20, requires "Diclofenac 1% topical gel (100gm Tube(s)) Apply 2 gms to affected area(s) by topical route 2 times per day". The physician's order, dated 3/12/21, showed "Tizanidine 4 mg Tablet, take 1 tablet daily at bedtime as needed. Both of these orders requires the diagnosis, condition or specific indications for administering the medications *Physician's order for resident 3, dated 3/10/21, showed Aricept 10 mg oral Tablet2 tab oral daily". The order requires the diagnosis, condition or specific indications for administering the medication. *RESIDENT 1 #1 - Doctor's orders will be sent to Doctor's office for Doctor to sign off on Physician's Order Sheet for Diagnosis. Physician's order for RESIDENT 1, dated 4/05/21, did have Assessment. and Plan on Summary of visit 4/05/21 showing Cellulitis of lower limb and medication Cephalexin 500 mg capsule. Physician's order for RESIDENT 1, dated 4/14/21, did have e-prescribed script dated 4/14/21 for Citalopram 10 mg Tablet Take 1 tab every day by oral route in the morning with diagnosis F03.91 Unspecified Dementia with behavioral disturbance, 1591000119013 Dementia with behavioral disturbance *RESIDENT 2 #2. - Physician's orders, dated 11/04/20, will be sent to Doctor's office for Doctor to sign off on Physician's Order Sheet for diagnosis *RESIDENT 3 #3. - Physician's order, dated 3/10/21, will be sent to Doctor's office for Doctor to sign off on Physician's Order Sheet for diagnosis
Standard #:	22VAC40-73-690-G
Description:	Based on resident record review, the facility failed to ensure that the action taken in response to the recommendations noted in the residents? medication review were documented in the residents? records. EVIDENCE: 1. The facility?s most recent medication review conducted by Collateral 1, dated 10/09/2020, showed the following recommendations: For resident 2: ?reevaluate frequent dosing interval; decrease doses per day ? (resident 2) receives divalproex sodium ER (extended release) administered at twice daily which is more frequent than recommended in the manufacturer?s product information ? For resident 3: ?items need clarification on the MAR/POS; Clarify? and ?Multiple eye drops; Separate administration time ? (resident 3) has an order for multiple ophthalmic drugs at one administration time?. 2. The records for residents 2 and 3 did not contain documentation of the action taken in response to these recommendations.
Plan of Correction:	*1 RESIDENT 2: Reevaluation of frequent dosing interval; decreasing dose per day of divalproex sodium ER (extended release) sending copu of order to physician with information. *1 RESIDENT 3: Items need clarification on the MAR; Clarify and Multiple eye drops; separate administration time; an order for multiple opthalmic drugs at one administration time; sending copy to physician with information for clarification.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure that a valid physician?s order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 04/23/2021, that showed ?Oxygen via Nasal Cannula at 2 L/Min Continuously scheduled?. The order does not contain the delivery source.
Plan of Correction:	*1 RESIDENT 1: Oxygen via Nasal Cannula at 2L/Min as needed for Dyspnea Ad lib. The order for Delivery Source is LINCARE who provides 7 tanks with a respirator