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 13, 2024

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 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/13/2024 8:30AM until 9:00AM and 05/13/2024 11:30AM until 3:15PM 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: 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: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: morning medication administration, medication cart audit, kitchen for special diet posting. 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 #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed whenever there is a significant change in the resident?s condition. EVIDENCE: 1. The record for resident 2 contained a signed physician?s order, dated 03/11/2024, for the facility to obtain a raised toilet seat for the resident. 2. The UAI for resident 2, dated 06/28/2023, indicates that the resident requires no assistance with toileting. 3. Interview with staff persons 4 and 5 confirmed that the resident now requires mechanical help with toileting and that the resident?s UAI should have been updated.
Plan of Correction:	I. The record for resident 2 has been updated to discontinue the order for raised toilet seat, as well as correctly documenting mechanical help with toileting on both the UAI and ISP. II. The administrator/designee will audit all resident belongings for DME to ensure correct documentation on the UAI and ISP. III. The administrator and/or designee will audit 10% of charts monthly to ensure to maintain compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) shall include description of identified needs and date identified based upon the uniform assessment instrument, admission physical examination, interview with resident, fall risk rating; if appropriate, assessment of psychological, behavioral, and emotional functioning; if appropriate, and other sources. EVIDENCE: 1. Resident 2 was admitted to the facility on 07/06/2023. The ISP for resident 2, dated 07/06/2023, indicates that the resident has a DNR order, and that no CPR will be performed; however, during on-site inspection a valid DNR order was not located in the resident?s record. 2. Interview with staff persons 4 and 5 confirmed that the facility did not have a valid DNR order for resident 2.
Plan of Correction:	I. The record for resident 2 has been updated to reflect the resident is a Full Code. II. The administrator/designee will audit all resident Code Status? to ensure correct documentation. III. The administrator/designee will audit 10% of charts monthly to ensure on going compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident?s condition. EVIDENCE: 1. The fall risk assessment document used by the facility indicates that if a resident has a score of 4 or more that they are considered at risk for falling. 2. The record for resident 2 contains a fall risk assessment, dated 03/05/2024, that identifies the resident as being considered at risk for falling. The ISP for resident 2, dated 07/06/2023, does not indicate that resident 2 is at risk for falling as an identified need. 3. The record for resident 4 contains fall risk assessments, dated 10/30/2023, 12/29/2023, 02/02/2024, 02/20/2024, 04/08/2024, 04/15/2024, and 04/22/2024, that all identify the resident as being considered at risk for falling. The ISP for resident 4, dated 02/02/2024, does not indicate that resident 4 is at risk for falling as an identified need. 4. The ISP for resident 4, dated 02/02/2024, indicates that the resident is receiving wound care to their right great toe from a home health agency; however, the ISP indicates the name of two different home health agencies that are providing the services and does not indicate when and where the services will be provided.
Plan of Correction:	I. The record for resident 4, and 2 have been updated to show ?risk for falling?. The record for resident 4 has been updated to accurately show the correct agency, and frequency of visits to the facility for wound care. II. The administrator/designee will audit all resident fall risk assessments, and ISPs for compliance. III. The administrator/designee will audit 10% of charts monthly to ensure on going compliance
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 3 contains a signed physician?s order, dated 04/18/2024, to hold the resident?s prescribed hydrochlorothiazide 25MG take one tablet by mouth every day ? hold if systolic blood pressure is below 140. The May 2024 medication administration record (MAR) for the resident indicates that the medication is administered daily at 8:00AM. 2. The document entitled ?Blood Pressure Sheet? for May 2024 that accompanies the resident?s May 2024 MAR indicates that the resident?s blood pressure was 122/72 on 05/02/2024 and 132/75 on 05/03/2024; however, the May 2024 MAR indicates that the medication was administered to the resident. Also, the May 2024 MAR does not indicate that the aforementioned medication was administered to the resident and the ?Blood Pressure Sheet? does not include a blood pressure reading for 05/05/2024. 3. This was also noted by staff persons 4 and 5.
Plan of Correction:	I. The administrator and Resident Care Coordinator (RCC) have completed education with all Register Medication Aides to review the doctors order of resident 3. II. The RCC/designee will continue to monitor resident 3 medication to ensure compliance. III. The RCC will continue to audit MAR?s regularly for accuracy of medication administration.