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: March 27, 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 inspector was on-site at the facility for each day of the inspection: 03/27/2023 9am until 2:30pm 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: 59 The licensing inspector 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-360-A
Description:	Based on resident record review and staff interviews, the facility failed to ensure that an emergency placement occurred only when the emergency is documented and approved by an independent physician or an adult protective services worker for private pay individuals. EVIDENCE: 1. The record for resident 4 contained a report of resident physical examination and an assessment of serious cognitive impairment, both dated 03/22/2023; however, the resident was admitted to the facility on 03/21/2023 and the two aforementioned documents are to be completed prior to the resident being admitted to an assisted living facility. 2. Interview with staff 6 indicated to the licensing inspectors (LI) during on-site inspection on 03/27/2023 that the resident was admitted to the facility as an emergency placement; however, there was no documentation of approval by an independent physician or an adult protective services worker that resident 4 was an emergency placement.
Plan of Correction:	? Administrator or designee will ensure that an emergency placement will not occur without proper documentation and approval by an independent physician or an adult protective service services worker.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 2 has a physician order dated 03/21/2023 for PT/OT eval and treatment as indicated. The ISP dated 02/25/2023 does not address this identified need. 2. A fall risk rating dated 12/09/2022 in the record for resident 7 has documentation that the resident is at a risk for falls. The ISP dated 07/06/2022 does not address this identified need.
Plan of Correction:	? Administrator or designee will endure that all identified needs are to be addressed on individualized services plans for all residents. POC: 04/06/2023 ? Administrator or designee will monitor for falls risk assessments and ensure that they are addressed on the ISP for each resident.
Standard #:	22VAC40-73-640-A
Description:	Based on observation during an audit of medication carts and staff interviews, the facility failed to implement a portion of its medication management plan. EVIDENCE: 1. The narcotic count key transfer sheets for medication carts A, B, C and D contained multiple days that did not contain the signatures of the outgoing and/or oncoming medication staff that the staff had preformed a count of the narcotics for the medication carts. Also, during on-site inspection on 03/27/2023 it was observed by one licensing inspector (LI) at approximately 9:59AM that staff 1 had already signed as the outgoing staff for medication cart C and at approximately 9:27AM and 9:31AM that staff 7 had already signed as the outgoing staff for medication carts A and B. Both staff 1 and 7 confirmed this was accurate and acknowledged that they should not have signed as the outgoing staff as they are both still on duty. 2. The facility?s medication management plan, revised 02/2021, indicates that for methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes that the narcotic log is to be completed by the off-going and on-coming registered medication aide and/or licensed practical nurse and a signature is required by both per shift.
Plan of Correction:	? Complete Medication management plan to be implemented at all times: narcotic count sheets to be completed by each shift RMA prior to accepting charge of the cart and at the appropriate time of each count. No signature shall be prior to the correct count time. Oversight by Administrator or designee to ensure that counts are being completed and signed for. POC: 03/28/2023 ? Narcotic log is to be completed by the off going and oncoming registered medication aide or LPN and signature is required by both per shift. Administrator or designee to monitor log books and endure that signatures are being placed on logs and counts are being completed by all necessary staff.
Standard #:	22VAC40-73-930-D
Description:	Based on resident record review, the facility failed to ensure that documentation of daily rounds were completed for residents with an inability to use a signaling device. EVIDENCE: 1. The March 2023 2 hour check off sheet for residents 5 and 6 do not have documentation of staff initials for 2 hour checks being completed from 7am until 3pm on 03/03/2023.
Plan of Correction:	? Daily rounds and 2 hour checks to be completed on all residents and documented using staff initials in the ADL binder. Administrator or designee to monitor ADL binders for all necessary staff signatures and initials.