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 26, 2021

Complaint Related: No

Areas Reviewed:

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 04/26/2021 and concluded on 04/30/2021 to follow up on previously cited standards from a complaint inspection from 12/29/2020. The Administrator was contacted by phone to initiate the inspection. The inspector emailed the Administrator a list of items required to complete the inspection. The LI reviewed documentation for five residents currently residing the in memory care unit and training for all staff from March 2021 until present. The information gathered during the inspection determined no repeat violations; however violations were cited and can be viewed on the violation notice.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on a review of facility documentation, the licensee failed to ensure compliance with relevant state law, with other relevant regulations and he facility?s own policies and procedures. EVIDENCE: 1. The facility did not have written certification for the training required under 16VAC25-220-80-A for staff 1 -11.
Plan of Correction:	All staff has been trained New hire will complete training as part of orientation or within first 7 days of employment.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. EVIDENCE: 1. The private pay UAI for resident 1, dated 03/16/2021, does not indicate the resident?s behavior pattern. 2. The private pay UAI for resident 2, dated 02/04/2021, showed that the resident does not need assistance with transferring. The individualized service plan (ISP) for resident 2, dated 02/04/2021, showed ?Resident will use assistive device to safely transfer (grab bars/furniture/Wheelchair), without staff assistance. Interview with staff 12 revealed that the ISP is correct and the UAI is incorrect.
Plan of Correction:	All needed corrections computed on 4-30-21. Assessor will be sure data on ISP correlate with UAI Administrator to review to ensure the aforementioned is done and accurate
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure residents? individualized service plans (ISP) included all required components. EVIDENCE: 1. The private pay uniform assessment instrument (UAI) for resident 1, dated 03/16/2021, showed that the resident needs physical assistance with dressing. The ISP for resident 1, dated 03/16/2021, showed the resident ?will receive physical assistance with dressing? and ?resident will be encouraged to put on clean clothes Supervision ONLY!? Interview with staff 12 revealed that the UAI is correct. The UAI for resident 1 showed the resident is ?disoriented ? some spheres, some of the time? and ?spheres affected: time, place @ times?. The ISP for resident 1 showed ?Disorientation of ? may orient upon discretion Support resident during episodes of disorientation, reassure safety at the facility?; however the ISP does not include a description of the spheres affected. 2. Resident 2 was admitted to the facility?s memory care unit on 02/04/2021. The ISP for resident 2, dated 02/04/2021, showed that the resident is ?ambulatory ? physically and mentally capable of exiting building during emergency?. Interview with staff 12 revealed that this information on the ISP is inaccurate for the resident as the resident is not mentally capable of exiting the building during an emergency.
Plan of Correction:	Needed correction completed. Staff completing ISP will include all pertinent data relating to resident Be sure to renew UAI/ISP to confirm data corresponds accurately. Executive Director and Director of Resident Care to review to confirm accuracy of data on UAI/ISP