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: Sept. 30, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 09/30/2024 8:30am until 11:00am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/10/2024 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 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 investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Personnel and resident care and related services A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-130-A
Description:	Based on resident record review and staff interviews, the facility failed to ensure that staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia reported suspected abuse, neglect, or exploitation of residents in accordance with that section. EVIDENCE: 1. The record for resident 2 has documentation in progress notes dated 09/09/2024 that resident 2 was observed to have been pushed by resident 1 and that resident 2 was sitting on the floor complaining of arm pain. Progress notes in the record for resident 2 also indicate that resident 2 was sent out to the local emergency room and diagnosed with a right distal radius fracture. 2. In an interview with staff persons 1, 2 and 3, who are mandated reporters, conducted on 09/30/2024, the licensing inspector (LI) asked if this resident-to-resident altercation had been reported as required. Staff person 1 expressed that the altercation had not been reported.
Plan of Correction:	Administrator or designee will ensure that they report any instances of suspected abuse, neglect or exploitation of residents, specifically in regards to resident to resident altercations.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The record for resident 1 has documentation of the resident having agitated behaviors in progress notes dated 08/15/2024. Progress notes dated 09/09/2024 in the record for resident 1 has that resident 1 had wondered into resident 2?s room and that an altercation then occurred between the two residents. The record also contains a physician order dated 07/04/2024 for Risperidone 0.25mg, take 1 tablet daily for agitation/mood. 2. In an interview with staff persons 2 and 3 conducted on 09/30/2024, it was expressed that resident 1 has periods of wandering behaviors. 3. The UAI dated 07/04/2024 in the record for resident 1 is inconsistent as it has documentation that resident 1?s behaviors are appropriate.
Plan of Correction:	The Administrator and DON will ensure that the resident?s UAI reflects current behaviors completely and accurately.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized services plans were updated as changes in a residents condition occurred. EVIDENCE: 1. The record for resident 1 has documentation in progress notes on 09/09/2024 that resident 1 had wondered into resident 2?s room and that an altercation then occurred between the two residents. 2. In an interview with staff persons 2 and 3 conducted on 09/30/2024, it was expressed that resident 1 has periods of wandering behaviors. 3. The ISP dated 07/04/2024 in the record for resident 1 does not include the identified need for wandering or of any services to be provided for this need.
Plan of Correction:	The Administrator and DON will ensure that the resident?s ISP reflects the resident?s current behaviors completely and accurately.