VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Liberty Ridge Memory Support - Pearls of Life
107 Monica Blvd.
Lynchburg, VA 24502
(434) 237-2268

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Dec. 17, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The Piedmont Licensing Office received an anonymous complaint in regards to Liberty Ridge Memory Support - Pearls of Life. The complaints alleges that the facility is short staffed, resident care needs are not being met, that there has been an increase with resident falls and that there are scabies present in the building. The LI for the facility conducted an on-site inspection on 12/17/2021 in conjunction with another LI and noted 54 residents to be in care on the day of inspection. A tour of the facility physical plant was conducted. Resident and staff records as well as other forms of facility documentation were reviewed. Interviews were conducted with staff. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations issued can be found on the violation notice. An exit interview was conducted on the day of inspection with the facility administrator to go over violations and to provide the opportunity to produce any additional information. If you have any questions please feel free to contact the LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on a review of the facility employee schedules, assignments sheets and staff interviews, the facility failed to ensure that the required number of direct dare staff were on duty in the facility special care unit. EVIDENCE: 1. The facility, which is an entire safe secure unit was noted to have a census of 54 on the day of inspection, which would require a minimum of 6 direct care staff to be on duty. The November and December 2021 employee schedule and assignment logs has documentation of only 5 direct care staff members working in the building during the 3pm to 11pm shift on 11/02/2021, 11/20/2021 through 11/24/2021, 11/26/2021 and 12/03/2021. An interview with staff person 1 expressed that the facility census has been 54 or above in November and December 2021 and that the employee assignment logs were correct for the number of direct care staff in the building on the 3pm to 11pm shift.
Plan of Correction:	Administrator/Designee will ensure the required number of staff are on duty in the special care unit at all times.
Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on a review of facility employee schedules, assignments sheets and staff interviews, the facility failed to ensure that the required number of direct dare staff were on duty during the night hours. EVIDENCE: 1. The facility, which is an entire safe secure unit was noted to have a census of 54 on the day of inspection, which would require a minimum of 6 direct care staff to be on duty during the night hours. The November and December 2021 employee schedule and assignment logs has documentation of only 5 direct care staff members or less working in the building during the night hours from 11/01/2021 through 12/17/2021. An interview with staff person 1 expressed that the facility census has been 54 or above in November and December 2021 and that the employee assignment logs were correct for the number of direct care staff in the building during the night hours.
Plan of Correction:	Administrator/Designee will ensure the required number of staff are on duty during the night time hours in the special care unit at all times.
Standard #:	22VAC40-73-70-C
Complaint related:	Yes
Description:	Based on a review of resident records and facility documentation, the facility failed to submit a written report within 7 days of the date of the incident. EVIDENCE: 1. The record for resident 6 has documentation that the resident fell out of her wheelchair and hit the floor on 09/05/2021. A hematoma was observed on the right side of resident 6's head and the resident was sent out to the emergency room for evaluation. As of the day of this inspection a written report of the incident was not submitted to the regional licensing office.
Plan of Correction:	The Administrator will ensure that all resident incident reports are submitted as required.
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that a fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care. EVIDENCE: 1. Incident reports for resident 1 has documentation that the resident has fallen eleven times between 09/03/2021 through 11/27/2021; however, there were no fall risk ratings for the falls on 09/12/2021, 09/29/2021, 09/30/2021 and 11/27/2021. Interview with staff 1 confirmed this was accurate. 2. Incident reports for resident 6 has documentation of the resident falling on 07/14/2021 and 09/05/2021. The last fall risk rating in the record for resident 6 dated 11/20/2020. Interview with staff person 1 confirmed this was correct.
Plan of Correction:	Fall Risk Ratings will be completed by designated staff person and placed in the resident record after a fall.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to review and update the individualized service plan (ISP) as the condition of a resident changes. EVIDENCE: 1. Facility incident reports for resident 1 show that the resident has fallen eleven times from the time period of 09/03/2021 through 11/27/2021. The ISP for resident 1 that was reviewed/updated on 07/14/2021, does not have documentation to reflect the residents change in condition for increase in falls. 2. The record for resident 4 contained ?nurse?s notes home health/hospice? notes from 11/03/2021 until the present showing the resident is receiving wound care to her sacrum. The resident?s most recent ISP, with a recent review date of 11/24/2021, does not indicate that the resident is receiving wound care to her sacrum. Interview with staff 1 confirmed that the resident is receiving this service and it is not indicated on her ISP. 3. Facility incident reports for resident 3 show that the resident has fallen 4 times from the time period of 11/30/2021 through 12/13/2021. The ISP for resident 3 that was reviewed/updated on 04/28/2021, does not have documentation to reflect the residents change in condition for increase in falls. 4. Facility incident reports for resident 6 show that the resident had a fall on 07/14/2021 and again on 09/05/2021. Documentation in progress notes dated 09/05/2021 indicate that resident 6 was sent to the emergency room for evaluation of a hematoma to the right side of the residents head. The ISP for resident 6, dated 11/20/2020 does not have documentation to reflect the residents change in condition for increase in falls.
Plan of Correction:	Administrator/Designee will ensure the resident ISP contains documentation to reflect change in condition.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on a review of resident records and staff interviews, the facility failed to ensure that resident bathing occurred at least twice a week, but more often if needed or desired. EVIDENCE: 1. The November 2021 ADL log for resident 1 has documentation that the resident only received a bath/shower on 11/04/2021, 11/07/2021 and 11/24/2021. 2. The November 2021 ADL lo for resident 3 has documentation that the resident only received a bath/shower on 11/08/2021, 11/17/2021 and 11/23/2021. 3. The November 2021 ADL log for resident 5 has documentation that the resident inly received a bath/shower on 11/17/2021.
Plan of Correction:	Administrator/Designee will ensure that personal care to including bathing is conducted twice weekly, but more often if needed or desired. This will be reflected on the resident ADL record.
Standard #:	22VAC40-73-580-E
Complaint related:	Yes
Description:	Based on a review of resident records and facility policies, the facility failed to follow their policy for monitoring warning signs of changes in physical or mental status related to nutrition. EVIDENCE: 1. The facility policy for food service and nutrition has documentation that all meal time food consumption will be logged in the ADL book to ensure that residents are consistently getting adequate food by mouth intake. The November and December ADL log for resident 1 through 5 have numerous blanks for the breakfast, lunch and dinner meals were their meal consumption amount was not logged as per the facility policy.
Plan of Correction:	Administrator/Designee will ensure meal consumption is documented in the resident ADL record.