VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Westminster Canterbury of Lynchburg
501 V.E.S. Road
Lynchburg, VA 24503
(434) 386-3500

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

Inspection Date: May 15, 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: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2023 9:00am until 2:00pm 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: 46 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 #:	22VAC40-73-440-D
Description:	Based on resident record reviews, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI dated 05/09/2023 in the record for resident 4 has documentation that the residents behavior pattern is wandering/passive less than weekly. A interdisciplinary note dated 03/21/2023 has documentation of the resident trying to spit, hit and becoming aggressive with staff. The UAI does not have documentation in the area for resident 4?s type of inappropriate behaviors.
Plan of Correction:	Resident Care Coordinator (RCC) corrected the UAI the date of the inspection (05/15/2023) to include the residents type of inappropriate behaviors.
Standard #:	22VAC40-73-680-D
Description:	Based on review of resident records and medication administration records (MARs), the facility failed to ensure that medications administered were consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1.The record for resident 6 has a physician order for Ozempic 0.25mg sub-q every Wednesday for DMII. This medication is a non-insulin injection. 2. The May 2023 MAR for resident 6 has documentation of staff initials who are RMA?s for the administration of this medication. 3. Page 53 of the current 68 hour registered medication aide curriculum revised in 2022 has documentation that ?Non-insulin injections a. Medication aides may not administer pursuant to 18VAC90-60-110(B)(5)?.
Plan of Correction:	Resident Care Coordinator (RCC) will provide education to all RMA?s and Charge Nurse?s (LPN) to ensure all medications administered are consistent with the standards in the medication aide curriculum. RMA?s are not to administer non-insulin injections.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. The bottom cabinet to the right of the desk on the facility safe, secure unit was noted to be unlocked on the day of inspection. 2 containers of Clorox Bleach Germicidal wipes, 2 containers of Sani Wipes and a container of Prempt Wipes were observed sitting on the shelf in the unlocked cabinet.
Plan of Correction:	The Clorox Bleach Germicidal wipes, Sani Wipes and Prempt wipes (Cleaning supplies) were removed from the bottom cabinet the day of inspection (05/15/2023) and stored in a locked area. Resident Care Coordinator (RCC) will provide education to staff regarding the importance of storing all cleaning supplies in a locked area.