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: June 18, 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 renewal study at the facility on 6/18/19 from 9am until 1:30pm in conjunction with two other LI's and noted 48 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 pass and the mid day meal were observed. Standards 325-A, 1120-B and 1130-A were reviewed with the facility administration for better understands of the regulations. Please respond back with a plan of correction with in 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 #:	22VAC40-73-320-A
Description:	Based on resident record reviews, the facility failed to ensure that a pre-admission physical for a resident was done within 30 days prior to admittance. EVIDENCE: 1. The record for resident 6, admitted to the facility on 3/14/19, has documentation that the history and physical completed on 1/24/19 was outside of the 30 day before admission required time frame.
Plan of Correction:	1. ED, RCC or designee will audit resident history & physical documentation for accuracy prior to their admission.
Standard #:	22VAC40-73-390-C
Description:	Based on document review, the facility failed to have updated written resident agreements. EVIDENCE: 1. The resident agreements for resident 5, admitted 10/31/2017, and resident 6, admitted 3/14/2019, lack the new elements required by 22 VAC 30-73-390-A, which were required as of 2/1/2018.
Plan of Correction:	1. ED have updated policy manuals to include all new elements required. BOM or designee will send the responsible party an acknowledgement of these new elements. Resident agreements have been updated and maintained in the resident?s charts.
Standard #:	22VAC40-73-440-A
Description:	Based on document review, the facility failed to complete a uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Faculties (22 VAC 30-110). EVIDENCE: 1. The private pay UAI for resident 5, dated 5/23/2019 is assessed incorrectly as it shows two types of assistance needed with eating/feeding: both mechanical/human help/physical assistance, and performed by others (spoon fed).
Plan of Correction:	1. ED, RCC or designee will review all UAI?s for appropriate completion upon each admission or update.
Standard #:	22VAC40-73-620-A
Description:	Based on resident record reviews, the facility failed to ensure that a dietician oversight was completed at least every six months. EVIDENCE: 1. The most recent dietician oversight completed at the facility was dated 11/26/18, which is past the six month requirement as of the date of inspection.
Plan of Correction:	1. Dietician will complete every 6 month review of special diets per standard.
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 June 2019 medication administration records (MARs) for resident 10 and noted a physician order for Albuterol Inhaler- inhale 2 puffs twice a day. The LI observed that only 1 puff was administered during the medication pass. The LI informed the RMA of this after the medication pass was completed so any corrections could be made.
Plan of Correction:	1. ED and or RCC will monitor registered medication aides med passes for accuracy and completion of medication administration weekly. 2. A 4-hour refresher course will be scheduled for all RMA?s to complete.
Standard #:	22VAC40-73-860-I
Description:	Based on observations, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. The dining room on the AL side of the building was noted to have a ulocked cabinet under the sink that contained several cleaning agents on the day of inspection.
Plan of Correction:	All cleaning agents were immediately removed. All staff have been trained on keeping chemicals locked at all times in ALF. Weekly routine checks will be completed by ED or designee.
Standard #:	22VAC40-73-870-A
Description:	Based on physical plant observations, the facility failed to maintain the interior of the building. EVIDENCE: 1. Stains were observed on the carpets in rooms 201 and 208.
Plan of Correction:	Professional carpet cleaning services have been scheduled for carpet cleaning. Spot cleaning will be maintained weekly and/or as needed from designated staff.
Standard #:	22VAC40-80-120-E-7
Description:	Based on physical plant observations, the facility facility failed to ensure that a copy of any special order issued by the department was posted in a prominent place at each public entrance of the licensed premises to advise consumers of serious or persistent violations. EVIDENCE: 1. The special order by the Department that was entered/signed on 10/17/18 was not post in the facility on the day of inspection.
Plan of Correction:	Special order was posted on the day of Inspection.