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 24, 2023

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: 04/24/2023 9:00AM until 1:00PM 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: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: noon-time meal, activity, medication passes and medication cart audits. 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 #:	22VAC40-73-50-A
Description:	Based on document and resident record review, the facility failed to ensure that its statement prepared and provided to prospective residents and his legal representative, if any, that discloses information about the facility contained all required components. EVIDENCE: The assisted living facility disclosure statement in the records for residents 4 and 5 did not include information of whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
Plan of Correction:	I. Resident #4, and 5 charts have been reviewed to ensure accuracy of Disclosure Statement paperwork. II. The administrator and/or designee will audit all resident charts to ensure required Disclosure Statement is on file. III. The administrator and/or designee will audit 10% of resident charts quarterly to ensure information is on file. IV. Date of Completion: Monday, July 31, 2023
Standard #:	22VAC40-73-210-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that for a facility licensed for both residential and assisted living care, all direct care staff attended at least 18 hours of training annually, except direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. EVIDENCE: 1. The record for staff 2, hired 05/02/2016, contained verification that staff 2 is a certified nursing assistant; however, during the most recent annual training period of 05/02/2021 through 05/01/2022, the record indicated that staff 2 received only 8 hours of the 12 hours of required annual training. 2. The record for staff 3, hired 03/29/2021, contained verification that staff 3 is a certified nursing assistant; however, during the most recent annual training period of 03/29/2022 through 03/28/2023, the record indicated that staff 3 received only 8 hours of the 12 hours of required annual training. 3. Interview with staff 4 confirmed that this was all of the training for staff 2 and staff 3 during their most recent annual training periods.
Plan of Correction:	I. Staff #2 and 3 records have been reviewed to ensure accuracy of annual training. II. The administrator and/or designee will audit staff records to ensure completion of annual training. III. The administrator and/or designee will audit 10% of staff records at random quarterly to ensure accuracy of all required training. IV. Date of Completion: Monday, July 31, 2023
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member maintained current certification in first aid. EVIDENCE: The record for staff 3 contained a Heartsaver First Aid CPR AED card which expired 03/2023. Interview with staff 5 confirmed that the certification for staff 3 had expired.
Plan of Correction:	I. Staff #3 has completed required First Aid/CPR training. II. The administrator and/or designee will audit all staff records to ensure annual certification is complete. III. The administrator and/or designee will audit 10% of staff records at random quarterly to ensure up to date CPR/ First Aid training is complete. IV. Date of Completion: Monday, July 31, 2023
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) was completed as required. EVIDENCE: 1. The UAI for resident 1, dated 02/20/2023, does not indicate whether the resident requires assistance with eating/feeding. 2. The UAI for resident 2, dated 10/26/2022, does not include the signature of the administrator or the designee on page 2. 3. The UAI for resident 3, dated 11/09/2022, indicates that the resident requires mechanical assistance and physical human assistance with stairclimbing. Interview with staff 4 and 5 revealed that the resident does not require physical human assistance with stairclimbing and only requires mechanical help and supervision human assistance.
Plan of Correction:	I. Resident #1, 2, and 3 have been reviewed for accuracy and compliance of Uniform Assessments (UAI?s). II. The administrator and/or designee will audit all current UAI?s to ensure accuracy. III. The administrator and/or designee will audit 10% of UAI?s quarterly to ensure accuracy. IV. Date of Completion: Monday, July 31, 2023
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) included all required components. EVIDENCE: 1. The ISP for resident 1, dated 02/20/2023, indicated that due to the resident?s inability to use the call bell due to cognitive or physical impairment that direct care staff are to conduct safety checks every two hours. Interview with staff 6 revealed that this is not an identified need of the resident and should not be included on the resident?s ISP. 2. The ISP for resident 2, dated 01/19/2023, does not indicate the name of the hospice agency that is providing hospice services to the resident. 3. The ISP for resident 4, dated 11/08/2022, indicates that the resident is receiving physical therapy and also that the resident is receiving wound care to the resident?s left lower extremity. Interview with staff 6 revealed that the resident is no longer receiving these services and should not be included on the resident?s ISP. 4. The UAI for resident 5, dated 01/05/2023, indicates that resident 5 requires supervision with stairclimbing; however, the ISP for resident 5, dated 04/11/2023, does not address this need.
Plan of Correction:	I. Resident #1,2,4 and 5 care plans have been reviewed for accuracy of compliance. II. The administrator and/or designee will audit current care plans for accuracy and update as needed. III. The administrator and/or designee will audit 10% of care plans quarterly to ensure accuracy. IV. Date of Completion: Monday, July 31, 2023
Standard #:	22VAC40-73-560-E
Description:	Based on resident record review and staff interview, the facility failed to ensure that a resident?s record was kept current. EVIDENCE: During on-site inspection on 04/24/2023, interview with staff 6 revealed that resident 2 receives hospice services. When one licensing inspector (LI) asked staff 6 for the hospice notes for the resident, staff 6 revealed that the hospice notes were not on-site for the resident and that she would have to get them faxed from the hospice agency.
Plan of Correction:	I. Hospice Notes have been obtained for resident #2. II. The nursing director/ or designee will audit resident records to ensure all notes are obtained from Hospice for resident chart. III. The nursing director and/or designee will randomly audit hospice charts monthly to ensure proper documentation is on file. IV. Date of Completion: Monday, July 31, 2023
Standard #:	22VAC40-73-950-E
Description:	Based on document review and staff interview, the facility failed to implement a semi-annual review on its emergency preparedness and response plan with all residents. EVIDENCE: During on-site inspection on 04/24/2023, one licensing inspector (LI) asked staff 4 for documentation of the facility?s semi-annual review on its emergency preparedness and response plan with all residents. Interview with staff 4 revealed that when residents are admitted to the facility that the facility will complete a review of the facility?s emergency preparedness and response plan during the resident?s required orientation; however, a semi-annual review with residents is not completed.
Plan of Correction:	I. Emergency Preparedness will be reviewed with all residents by June 7, 2023. II. The administrator will audit all resident charts for emergency preparedness training to ensure completion. III. The administrator and/or designee will audit 10% of charts monthly to ensure to maintain emergency preparedness. IV. Date of Completion: Monday, July 31, 2023