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 3, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-80 COMPLAINT INVESTIGATION.

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 complaint inspection was initiated on 05/03/2021 and concluded on 05/04/2021. A complaint was received by the department regarding allegations in the areas of personnel; the facility's administrator of record is also the administrator of record at another licensed assisted living facility in Virginia. The Administrator was contacted by telephone to conduct the investigation and to discuss the complaint. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-170-B
Complaint related:	Yes
Description:	Based on document review and interview, the facility failed to ensure that the combined total licensed capacity of the facilities served by the administrator is 40 or fewer residents, and that each facility served is within a 30-minute average one-way travel time to the other facility. EVIDENCE: 1. Documentation from the facility (facility 1) stated that staff 1 was appointed as the administrator of record at this assisted living facility effective 03/25/2021. 2. Interview with Collateral 1 stated that staff 1 was appointed as the administrator of record at another licensed assisted living facility (facility 2) on 01/01/2021, and remains the administrator of record to date. 3. The license capacity of facility 1 is 61 and the license capacity of facility 2 is 60 which combined is more than the standard allows. 4. According to Google Maps, the mileage between facility 1 and 2 is 113 miles with a drive time of 2 hours and 8 minutes which is more than the standard allows.
Plan of Correction:	Response to the stated deficiencies does not constitute an admission or an agreement of the truth of the facts alleged or conclusions set forth in the statement of deficiency or corective action report; the plan of correction is prepared solely as a matter of compliance with state law Staff 1 is the administrator of record for only The Elms of Lynchburg