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: April 23, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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 SANCTIONS.

Comments:

The LI for The Elms of Lynchburg conducted an unannounced monitoring visit at the facility on 4/23/19 from 8:45am until 3:00pm under the supervision of the LA and noted 50 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the facility physical plant was conducted and the morning medication and mid day meal were observed. Please respond back to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on review of staff records, the facility failed to ensure direct care staff attended at least 18 hours of annual training. EVIDENCE: 1. Staff person 3, hired on 6/22/2016, had only 9 hours of annual training.
Plan of Correction:	1. ED or BOM will audit staff records monthly to ensure trainings are accurate and updated. 2. ED or BOM will audit staff records monthly to ensure required trainings are complete.
Standard #:	22VAC40-73-210-F
Description:	Based on review of staff records, the facility failed to ensure that at least two of the required hours of training focused on infection control and prevention. EVIDENCE: 1. The record for staff person 3 did not include documentation to show that the staff person received a minimum of two hours of infection control and prevention training.
Plan of Correction:	1. ED or BOM will audit staff records monthly to ensure trainings are accurate and updated. 2. ED or BOM will audit staff records monthly to ensure required trainings are complete.
Standard #:	22VAC40-73-310-B
Description:	Based on review of resident records, the facility made determinations to admit individuals without completing a required mental health screening and pre-admission interviews. EVIDENCE: 1. The records for resident 2, admitted on 3/14/2019, and resident 3, admitted on 4/12/2019, did not contain documented interviews between the administrator/designee and individual/legal representative prior to or on the date of admission. 2. The UAI dated 3/14/19 for resident 2 shows the resident has abusive/aggressive/disruptive behaviors less than weekly; however, a mental health screening was not conducted prior to the residents admission on 3/14/19.
Plan of Correction:	1. ED or designee will begin using a pre-admission tool during interview with new residents during their initial assessment. 2. ED or designee will ensure a mental health screening is completed on all residents upon admission.
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident record, the facility failed to ensure the resident?s physical was completed as required. EVIDENCE: 1. The physical examination form for resident 3, dated 4/9/2019, listed the following allergies, but did not include the reactions to those allergens: Codeine, Enalapril, Tramadol, ACE Inhibitors.
Plan of Correction:	1. RCC or designee will obtain allergy reactions during admission process.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record reviews, the facility failed to ensure a fall risk rating was completed after a resident falls. EVIDENCE: 1. The record for resident 1, assessed as assisted living level of care, has documentation of the resident falling on 2/19/19 and again on 2/25/19. The record did not have documentation of a fall risk rating being completed for these falls.
Plan of Correction:	1. ED, RCC or designee will ensure fall risk rating has been completed after each fall.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record reviews, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required. Evidence: 1. The private pay UAIs for residents 2 and 6 show the residents have been assessed as needing medications administered by both lay person and professional nursing staff. Both residents require only the assistance of a lay person. 2. The UAI for resident 2 has the resident assessed as both, not needing help with wheeling and that wheeling is not performed. This UAI also shows a reassessment was completed on 4/14/2019; however, the LI was unable to decipher what changes, if any, were made. The revision was signed as being completed by an assisted living facility employee, but lacks the required signature of the Administrator or designee. 3. The UAI originally dated 5/24/18 in the record for resident 1 has documentation of a reassessment being conducted for this resident but the UAI does not have the date that the reassessment was completed. 4. The UAI originally dated 8/7/18 in the record for resident 10 has documentation of a reassessment being conducted for this resident but the UAI does not have the date that the reassessment was completed.
Plan of Correction:	1. ED or designee will review and update all UAI reflecting the necessary documentation of who will be administering medications to the resident. 2. ED or designee will review and update all UAI to reflect the correct option for wheeling throughout the facility. 3. ED or designee will review all UAIs for completion and accuracy of the document. 4. ED or designee will review all UAI for completion and accuracy of the document.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record reviews, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The ISP for resident 2, dated 3/14/2019, lacks written description of the physical assistance services that need to be provided to the resident with bathing. This ISP also shows the resident is getting safety checks every 2 hours due to her inability to use call bell due to cognitive or physical impairment. Interviews with facility staff reveal this resident does not require safety checks as written, nor are they being provided. 2. The ISP for resident 3, dated 4/12/2019, lacks written description of the physical assistance services that need to be provided to the resident with bathing, dressing, and toileting. 3. The record for resident 1 has a physician order dated 3/25/19 for home health for wound care needs and a physician order dated 3/29/19 for size F tubigrip to both lower legs. The ISP dated 7/12/18 does not address these identified needs. 4. The ISP for resident, 9 dated 7/12/18, lacks written description of the physical assistance services that need to be provided to the resident for bathing, dressing and toileting. 5. The record for resident 10 has documentation of the resident falling on 8/23/18, 10/25/18, 11/4/18 and 11/15/18. The ISP dated 8/10/18 does not address the residents need for fall risk/prevention.
Plan of Correction:	1. ED or designee will review all ISPs to ensure accuracy of information documented. 2. ED or designee will ensure individualized documentation of the resident?s needs are clearly reflected on the ISPs. 3. ED or designee will review all ISPs receiving home health services to ensure accuracy of beginning and ending of services. 4. ED or designee will ensure individualized documentation of the resident?s needs are clearly reflected on the ISPs. 5. This resident?s ISP has been updated to reflect the changes in her fall status.
Standard #:	22VAC40-73-650-E
Description:	Based on review of resident record, the facility failed to ensure that a resident?s record contained all physician?s orders. EVIDENCE: 1. The April 2019 medication administration record (MAR) for resident 2 shows the order to take Vitamin D3 every week on Saturday was discontinued on 4/2/2019; however, the record did not contain a physician?s order to discontinue this medication.
Plan of Correction:	1. MAR to Cart audit will be completed by RCC and/or designee weekly to ensure all orders are current.
Standard #:	22VAC40-73-680-C
Description:	Based on observations made, the facility failed to ensure that medications were administered not later than 1 hour after after the facilities standard dosing schedule. EVIDENCE: 1. The LI observed on the day of inspection that the 8am medications for resident 11 were not administered until 9:40am.
Plan of Correction:	1. RCC or designee will monitor time changes made by the pharmacy when verifying orders.
Standard #:	22VAC40-73-680-D
Description:	Based on observations of the morning medication pass, the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. The LI reviewed the April 2019 medication administration records for resident 4 and noted a physician order for Fluticasone Propionate nasal spray, 2 sprays in each nostril daily. The LI observed that only 1 spray in each nostril was administered during the medication pass. The informed the RMA of this after the medication pass was completed so any correction could be made. 2. The record for resident 7 has a physician order for Fluticasone OTC nasal spray, 2 sprays in each nostril daily. The LI observed a half full bottle of Fluticasone spray in the medication cart for resident 7 with an open dated on 3/12/19. Staff initials are present every day from 3/12/19 to the day of inspection for administering this medication but this bottle contains 120 metered doses and would only be good for a 30 day supply.
Plan of Correction:	1. ED, RCC will observe registered medication aides for accuracy and completion of medication administration weekly. A review was completed by ED with all registered medication aides. 2. Med cart to MAR audit will be completed weekly by RCC and/or designee to ensure bulk medications are being administered as ordered?
Standard #:	22VAC40-73-680-E
Description:	Based on review of resident records, the facility failed to ensure medical procedures or treatments ordered by a physician were provided accorded to his instruction, documented, and maintained in the resident record. EVIDENCE: 1. The record for resident 2 contained a physician?s order, dated 3/15/2019, to monitor vitals daily for 5 days. The record did not contain any documentation to show this order was been followed. 2. The record for resident 3 contained a physician?s order, dated 4/9/2019, for heel protectors to be applied QHS. The record did not contain any documentation to show this order has been followed.
Plan of Correction:	1. ED, RCC or designee will ensure all MD orders are being followed by reviewing medication compliance report daily. 2. Ancillary staff will leave any order changes for RCC to fax to pharmacy to reflect on MAR.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record reviews, the facility failed to ensure all required documentation was included on medication administration records (MARs). EVIDENCE: 1. The April 2019 MARs for residents 3, 4, 6, 7, 8, 10 and 11 show asterisks (*) by several initials, which according to the Information Key, indicates there is a reason/comment; however, there were no nurses or exception notes to provide information regarding these medications. This MAR also showed dates where staff initials were in parenthesis (), which according to the Information Key, indicates medication was not administered or not charted. 2. The March 2019 MAR for resident 6 shows no documentation for the scheduled 9am doses of Calcium, Docusate Sodium, and Vitamin D on 3/28, or the scheduled 9am dose of Atorvastatin on 3/29. This same MAR shows ?x? on several dates for which scheduled medications were to be given; however, there are no nurses or exception notes to explain this documentation. 3. The March and April 2019 MAR for resident 11 has the physician order for Breo Ellipta, 1 puff by mouth daily double printed on the MAR. Staff initials are signed off on both entries on 3/1/19 through 3/9/19, 3/28/19 and 4/1/19. 4. The March 2019 MAR for resident 10 has the physician order for Spriva Respimat inhaler, 2 puffs daily double printed on the MAR. Staff initials are signed off on both entries on 3/11/18.
Plan of Correction:	1. All medication pass times are being addressed with pharmacy and adjusted to eliminate charted late entries. 2. ED, RCC or designee will review administration compliance daily to eliminate re-occurrence of missed medications. 3. ED, RCC or designee will review orders for duplicates put in by pharmacy one daily basis. Pharmacy has been alerted of the re-occurring issue.
Standard #:	22VAC40-73-700-1
Description:	Based on review of resident record, the facility failed to ensure that physician?s orders for oxygen therapy contained all required components. EVIDENCE: 1. The record for resident 3 contained a physician?s order for 2LPM via nasal cannula every hour as needed for decreased oxygen. The order did not include the delivery device, as required.
Plan of Correction:	1. All orders will be reviewed by RCC prior to verifying for completeness of meeting all the medication administration rights.