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: Aug. 24, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

A non-mandated complaint inspection was initiated on 08/23/2021 and concluded on 09/14/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, staffing and building and grounds. The Community Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Community Director a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 08/24/2021. The Community Director and the licensing inspector had a discussion regarding building and grounds. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Violations not related to complaint; however, cited during the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to complete the Uniform Assessment Instrument (UAI) whenever there is a significant change in the resident?s condition. EVIDENCE: 1. The private pay UAI for resident 2, dated 12/18/2020, identified the resident?s behavior pattern as appropriate. 2. Staff notes for resident 2 showed that on 06/19/2021 at 10:30 PM that resident ?Yells for RA (resident assistant) to leave her alone.? and on 08/09/2021 that ?Resident getting increasingly agitated with staff when they try to help with ADLs (activities of daily living).? 3. The UAI for resident 2 had not been updated to reflect this change. Interview with staff 1 confirmed that this was accurate.
Plan of Correction:	1. Resident #2 UAI was updated immediately to reflect the needed changes and reviewed for accuracy. 2. Administrator and/or designee will review all current UAIs for compliance. 3. Administrator or designee will randomly audit 2 charts monthly to ensure ongoing complaince.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs. EVIDENCE: 1. During on-site inspection on 08/24/2021, the licensing inspector observed resident 1 sitting in a wheelchair and the resident self-propelling herself in the wheelchair to move from room to room in her apartment. Interview with staff 1 revealed that the resident does use a wheelchair. The ISP for resident 1, with a recent review date/update on 05/06/2021, does not show that resident 1 uses a wheelchair. 2. The record for resident 1 contained fall risk ratings completed on 02/07/2020, 02/09/2021, 07/11/2021 and 08/16/2021 that identify the resident as a fall risk. The ISP, with a recent review date/update on 05/06/2021, does not address that the resident is a fall risk.
Plan of Correction:	1. Resident #1 ISP was updated immediately to reflect needed changes and reviewed for accuracy. 2. Administrator and/or designee will review all current records for continued compliance. 3. Administrator and/or designee will randomly audit 2 ISPs monthly to ensure ongoing compliance.