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: May 16, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 05/16/2022 7:40AM through 1:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 22 The licensing inspectors completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication pass, audit of facility?s medication carts, noon-time meal An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on resident record review, the facility failed to ensure that direct care staff received the required numbers of hours of training annually. EVIDENCE: The training log in the record for staff 1, hired on 05/02/2016, has documentation that staff 1 only received 1.5 hours of annual training between 05/02/2021 and 05/02/2022.
Plan of Correction:	Staff 1 had completed required packet of training but had failed to turn in paperwork to be reviewed by Staff 3 and 6 on time. Going forward all staff will be required to turn in at least 1-2 hours of training per month for review of which will include scheduled facility training.
Standard #:	22VAC40-73-210-F
Description:	Based on resident record review, the facility failed to ensure that direct care staff received at least 4 hours of training for adults with mental impairments and at least 2 hours of training on infection control and prevention annually. EVIDENCE: 1. The record for staff 1, hired on 05/02/2016, does not have documentation of this employee receiving any annual training in adults with mental impairments or any training in infection control and prevention. 2. The record for staff 2, hired on 03/26/1996, has documentation that this employee has only had 1 hour of annual training on infection control and prevention.
Plan of Correction:	Staff 1 has provided facility with training in mental impairments and infection control and prevention. Staff 2 has provided facility with an addtional hour of required training on infection control and prevention.
Standard #:	22VAC40-73-310-D
Description:	Based on resident record review and staff interview, the facility failed to provide written assurance to residents or legal representatives that the facility has the appropriate license to meet his care needs at the time of admission. EVIDENCE: The records for resident 2, admitted 05/10/2022, and resident 5, admitted 02/19/2022, did not contain documentation that written assurance had been given to residents 2 and 5 or their legal representatives.
Plan of Correction:	This was an oversight of Staff 5, Community Director, as there was no AL Administrator at the time of move in. This written letter of assurance is completed by the AL Admin.prior to move-in or transfer of new resident. All paperwork for new residents will be completed by new AL Admin. moving forward. Residents 2 and 5 have received the written letter of assurance and signed the document.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to review and update the fall risk rating for a resident after a fall. EVIDENCE: Facility staff documentation in the record for resident 3 indicated that on 03/24/2022 the resident had a fall in the bathroom. The record for the resident did not include an updated fall risk rating to reflect this fall.
Plan of Correction:	Staff 3, RCC has updated the "Fall Risk Assessment" form to reflect the fall on resident 3 from 03/24/2022. The "Fall Risk Assessment" form will be completed on all residents moving forward at the time of the incident and placed in the file.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to obtain all resident personal and social information as required. EVIDENCE: 1. The ?Resident ? Personal/Social Data? for resident 2, admitted 05/10/2022, did not contain the following information: service in Armed Forces (if applicable), address from which received (if different), responsible individual (if needed), clergyman/place of worship (if applicable), next of kin (if known), local department of social services (if applicable), other agency (if applicable), and current behavioral and social functioning strengths. 2. The ?Resident ? Personal/Social Data? for resident 4 did not contain the following information: admission date and the resident?s interest and hobbies. 3. The ?Resident ? Personal/Social Data? for resident 5 did not contain the following information: admission date, address from which received (if different), responsible individual (if needed), clergyman/place of worship (if applicable), personal dentist, local department of social services (if applicable), other agency (if applicable), and current behavioral and social functioning strengths.
Plan of Correction:	1. Staff 3, RCC has updated the "Personal/Social Data" form for resident 2 with all required missing information. *Armed Forces *Address *Responsible Individual *Clergyman/place of worship *Next of kin *SS Information *Behavioral and Social functioning 2. Staff 3, RCC has updated "Personal Social Data" form with all missing required information. *Admission Data *Interest and Hobbies 3. Staff 3, RCC has updated "Personal Social Data" form with all missing required information. *Admission Data *Address *Responsible Individual *Clergyman/place of worship *Personal Dentist *SS Information *Behavioral and Social functioning In the future, AL Admin. will review and complete "Personal Social Data" forms for new residents. AL Admin. will review all existing files and update any missing information.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) contained all required components. EVIDENCE: 1. The UAI, dated 02/19/2022, for resident 5 did not indicate how the resident takes her medications. 2. The individualized service plan (ISP) for resident 5, dated 02/19/2022, indicated that the resident needs mechanical and physical assistance with handrails and steps regarding stairclimbing. The UAI, dated 02/19/2022, for the resident indicates that the resident requires no assistance with stairclimbing. Interview with staff 3 indicated that the ISP is correct and the UAI is incorrect.
Plan of Correction:	1. Staff 3 has updated resident 5's UAI to indicate medications to be administered by RMA's and LPN. 2. Staff 3 has updated resident 5's UAI to match ISP to include all identified needs. *Resident needs mechanical and physical assistance with handrails and steps regarding stairclimbing.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to update the individualized service plan (ISP) for a significant change of a resident?s condition. EVIDENCE: 1. The uniform assessment instrument (UAI), dated 05/10/2022, for resident 2 indicated that the resident is disoriented some spheres, all the time; however, the spheres affected are not documented. 2. The UAI, dated 02/19/2022, for resident 5 indicated that the resident requires human help supervision with dressing and mechanical help with transferring; however, the ISP for the resident, dated 02/19/2022, does not indicate the resident needs assistance with dressing and transferring. Interview with staff 3 indicated that the resident does required this assistance.
Plan of Correction:	1. Staff 3 has updated resident 2's UAI to indicate that resident is disoriented some spheres, some of the time, not all of the time. Incorrect box was checked. 2. Staff 2 has updated resident 5's ISP to indicate that resident does require human help supervision with dressing and does require mechanical help with transferring. UAI is correct.
Standard #:	22VAC40-73-640-A
Description:	Based on medication cart audit and document review, the facility failed to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes in their medication management plan. EVIDENCE: The May 2022 ?Change of Shift Controlled Medication Count Sheet? log was lacking several signatures of medication administration staff that were either coming on shift to administer medications or leaving their shift after they had administered medications. Interview with staff 3 revealed that the facility uses this log for medication staff to sign off on once they have completed the count of all controlled substances with another medication administration staff. The facility?s medication management plan did not include that the facility uses this log to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Plan of Correction:	Staff 3 and 6 have updated "Medication Management Plan to incude "Controlled Medication Sheet" to be completed at shift change by RMA's during med count. New plan will be given to each RMA for review and signature. Staff 3 has reviewed the "Controlled Medication Sheet" with RMA's and corrected signatures that were missing.
Standard #:	22VAC40-73-680-M
Description:	Based on observations made of the facility medication cart and staff interviews, the facility failed to ensure that medications ordered for PRN use were available and properly labeled and stored at the facility. EVIDENCE: The May 2022 medication administration record (MAR) for resident 7 has a physician order for Deep Sea 0.65% Nasal Spray, 1 spray as needed by nasal route for allergenic rhinitis. Observations made of the facility medication cart noted that this medication was not available and properly stored at the facility. An interview with staff 1 and 2 expressed that the medication was not on-site at the facility.
Plan of Correction:	Staff 3 requested an order from Physician's office to discontinue nasal spray for resident 7 of which has been v/o by NP.
Standard #:	22VAC40-73-980-H
Description:	Based on observations of the facility physical plant and staff interviews, the facility failed to ensure that at least a 48 hour supply of emergency water was maintained on-site at the facility. EVIDENCE: During observations made of the facility?s emergency food and water supply it was noted that the facility did not have at least 48 hours of emergency water on-site. An interview conducted with staff 4 expressed that this was correct and that an emergency water supply was not currently stored at the facility.
Plan of Correction:	Facility usually maintains an adequate water supply on site; however, facility did not have 48 hours of emergency water on site at inspection. Water was ordered immediately from our food supplier and delivered the next day. Stored water supply had been depleted with resident deliveries during COVID outbreak in early 2022 and during water repair from backflow replacement. Failed to re-order.
Standard #:	22VAC40-73-990-C
Description:	Based on document review and staff interview, facility staff on each shift, at least once every six months, failed to participate in an exercise in which the procedures for resident emergencies are practiced. EVIDENCE: Documentation provided to the licensing inspector on the day of inspection indicated that the last practice by staff for resident emergencies was conducted on 11/15/2019. Interview with staff 5 indicated that this is accurate.
Plan of Correction:	Long term AL Administrator's unexpected early retirement in 2021 and new AL Administrator's abrupt departure thereafter, Staff 5 failed to complete specific training "Resident Emergencies" for department. Staff 5 was not aware at the time this had not been completed. Unable to schedule training in early 2022, January - March due to COVID in AL. Staff 3, 5 and 6 will schedule and complete a required training for all AL staff.