VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Elms of Lynchburg
2249 Murrell Road
Lynchburg, VA 24501
(434) 846-3325

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 15, 2024 and May 16, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2024 8:00AM until 5:00PM and 05/16/2024 8:30AM until 11:00AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/30/2024 regarding allegations in the areas of: resident care and related services & additional requirements for facilities that care for adults with serious cognitive impairments An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: additional requirements for facilities that care for adults with serious cognitive impairments. A violation notice was issued; any violation(s) not related to the complaint 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on resident record review, prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: The Assessment of Serious Cognitive Impairment document in the record for resident 1 indicates on page 2 of 2 that the resident is able to recognize danger or protect his/her own safety and welfare.
Plan of Correction:	22VAC40-73-1090-A Facility will ensure that the Assessment of Serious Cognitive Impairment is completed accurately in its entirety for all admissions into the Memory Care Community. Initiated Date: 6/3/2024 Completion Date: 7/29/2024; ongoing The Director of Nursing and Resident Care Manager will audit all Memory Care residents? charts to ensure adequate completion of the Assessment of Serious Cognitive Impairment screening. The Marketing and Sales Manager and the Director of Nursing will conduct an admissions medical record audit prior to all admissions to ensure that all forms are completed correctly and signed by appropriate physician within 30 days prior to admission. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-1120-F
Complaint related:	Yes
Description:	Based on staff interview, the facility failed to ensure there shall be a designated staff person responsible for managing or coordinating the structured activities program and the staff person shall be on site in the special care unit at least 20 hours a week, shall maintain personal interaction with the residents and familiarity with their needs and interests, and shall meet at least one of the qualifications in 22VAC40-73-1120-F-1 through 5. EVIDENCE: The licensing inspector (LI) received a complaint that the facility?s safe, secure unit does not have anyone working in the activity?s department. It was confirmed through interviews with staff persons 1, 2 and 3 that this is accurate. Interview with staff person 1 revealed there has been no designated staff person responsible for managing or coordinating the structed activities program for the facility?s safe, secure unit for the past 3-6 months that meet the requirements of this standard.
Plan of Correction:	22VAC40-73-1120-F Facility will ensure that a designated personnel will carry out activities within the facility for required hours to meet both AL and MC community standards. Initiated Date: 6/3/2024 Completion Date: 6/28/2024 Executive Director will assign required activities to qualified staff member that have met the 1120 F 1 through 5 standards. The Qualified Staff Member will fulfill role/duties in both Assisted Living and Memory Care units Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the resident or his legal representative. EVIDENCE: The ISP in the record for resident 1, dated 12/27/2023 and a subsequent review/update of plan dated 01/27/2024, is not signed and dated by the resident or their legal representative.
Plan of Correction:	22VAC40-73-450-E Facility will ensure all resident?s comprehensive individualized service plans (ISP) are reviewed and updated at least once every 12 months. Initiated Date: 6/3/2024 Completion Date: 7/29/2024; ongoing The Director of Nursing and Resident Care Manager will audit all existing resident charts. The Director of Nursing will implement a monitoring/audit system for all residents in the community for ISP updating and/or renewal. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-650-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that physician?s or other prescriber?s oral orders shall be reviewed and signed by a physician or other prescriber within 14 days. EVIDENCE: The record for resident 1 contains a voice order, dated 03/19/2024, to discontinue donepezil, increase quetiapine to 100MG at bedtime and hydroxide 25MG at bedtime as needed. The voice order does not contain a signature of a physician or other prescriber.
Plan of Correction:	22VAC40-73-650-C Facility will ensure all residents charts are reviewed, updated, signed by physician, have an appropriate diagnosis and dosage, and kept current regarding physician orders and pharmacy recommendations. Initiated Date: 6/3/2024 Completion Date: 7/29/2024 The Director of Nursing and Resident Care Manager will audit all existing resident charts to ensure all orders are current and accurate. The Director of Nursing and Resident Care Manager will implement a monitoring/audit system for all residents in the community. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. After 8 weeks, Director of Nursing will be required to audit 2 residents? charts per week for accuracy. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee ? audit tool will be turned in weekly.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observation during a tour of the facility, the facility failed to ensure all furnishings, fixtures, and equipment, including showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. EVIDENCE: At approximately 8:23AM, the LI noted a dark, black substance underneath the drain cover in the shower in resident 1?s bathroom. In addition, the white laundry basket located in the resident?s shower contained a dark brown/black substance around a portion of the top of the basket.
Plan of Correction:	22VAC40-73-870-E Facility will ensure cleanliness of facility and its structure. Initiated Date: 6/3/2024 Completion Date: 7/17/2024; ongoing The Maintenance Tech and Housekeeping staff will begin deep cleaning of all resident?s rooms and bathrooms over the next 2 weeks, ensuring that all resident?s rooms and bathrooms are free from chemicals and/or debris. The Executive Director will provide all department managers with an assigned Resident Room Walk-through check list. All residents? rooms will be inspected weekly over the next 8 weeks for cleanliness, compliance, and safety. Audit Document: Room Rounds Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee