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: Jan. 5, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The licensing inspector (LI) for The Elms of Lynchburg initiated an on-site, unannounced, non-mandated monitoring inspection on 01/05/2022 at 9:45AM regarding a self-reported incident of an elopement of a resident from the facility's safe, secure unit. Preliminary findings were reviewed with the Administrator during the on-site inspection on 01/05/2022. An exit interview was conducted with the Administrator via phone on 01/18/2022 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Administrator provided additional information on 01/19/2022 to the LI via email. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-1150-A
Description:	Based on staff interview and documentation, the facility failed to ensure that doors that lead to unprotected areas were monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices or perimeter fence gates. EVIDENCE: Incident report from staff 1 emailed to the licensing inspector (LI) on 12/27/2021 regarding resident 1?s elopement stated that the resident ?was able to tell staff what happened and demonstrate how he was able to push four fingers under the lip of the door and pull the door open them [sic] proceeded to go through the main door.? Interview with staff 1 confirmed that the door the resident was ?able to push four fingers under the lip of the door? was the door of the safe, secure unit. Resident opened the door of the safe, secure unit by placing his four fingers under the lip of the door where the two safe, secure doors overlap. Once resident was able to go through the doors of the safe, secure unit, he was then able to access the facility?s assisted living section of the building and then exited the main door out into the parking lot of the facility. Staff 1 stated that she was informed by Collateral 1 that the magnet that is located on the top part of the doors to the memory care malfunctioned and that was how the resident was able to open the door in the facility?s safe, secure unit.
Plan of Correction:	Repairs to door (Maglocks) repaired/done immediately by First Fire Sprinklers Staff will continue to conduct frequent rounds ? head count every 2 hours First Fire will continue to provide monitoring monthly checks. Maintenance tech will continue frequent checks throughout the week.
Standard #:	22VAC40-73-70-B
Description:	Based on documentation review, the facility failed to report all required information to the regional licensing office within 24 hours of a major incident that has negatively affected or that threatened the life, health, safety, or welfare of any resident. EVIDENCE: The following email was sent to the licensing inspector (LI) by staff 1 on 12/23/2021 at 12:59PM that stated, ?Want to inform you (LI) that resident was returned to the community, no injuries noted, POA and Attending Physician aware. Completed report will be sent upon it [sic] completion.? The email did not contain the name of the resident involved in the incident.
Plan of Correction:	Future notifications of incidents reports will contain residents name at initial reporting and via email completed report will be followed with residents name within the next 5-7 days.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) was reviewed and updated as needed as the condition of the resident changes. EVIDENCE: 1. Resident 1 was admitted to the facility?s safe secure unit on 10/27/2021. 2. The record for resident 1 contained a resident progress note by staff 2, dated 11/08/2021 at 2:48 PM, that ?resident talks about going home, not having his wallet and looking for keys. Resident is easily redirected with activities or 1 on 1.? and a resident progress note by staff 3 on 11/08/2021 at 2:55PM that ?resident packed all his stuff and stated he was leaving prn given?. Documentation by staff 4 sent to the resident?s physician, dated 11/18/2021, stated that ?resident fell trying to get out of memory care?. 3. The individualized service plan (ISP) for the resident, with a subsequent review/update of plan signed on 12/01/2021 by staff 1 and 2, does not address identified needs of the resident talking about going home, not having his wallet, looking for his keys, packing all his stuff, stating he was leaving, and the resident?s fall due to trying to get out of memory care.
Plan of Correction:	Staff in-serviced on following information on ISP update implement recommendation immediately if becomes difficult to redirect. Staff educated on identifying the needs of resident follow and implement recommendation as means of redirecting. See attached ? Recommendations to be implemented if behaviors/agitation is observed initiate conversation on subject matter of interest ? military, farming, call his daughter. Staff instructed to document in residents chart also on 24 hour report to support findings of recommendations
Standard #:	22VAC40-73-460-D
Description:	Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 1, dated 10/26/2021, showed that the resident is ?nonambulatory by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person? and the ?Assessment of Serious Cognitive Impairment? for resident 1, dated 10/26/2021 showed that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger or protect his/her own safety and welfare. 2. Resident 1 was admitted to the facility?s safe secure unit on 10/27/2021. 3. The record for resident 1 contained a resident progress note by staff 2, dated 11/08/2021 at 2:48 PM, that ?resident talks about going home, not having his wallet and looking for keys.? and a resident progress note by staff 3 on 11/08/2021 at 2:55PM that ?resident packed all his stuff and stated he was leaving prn given?. Documentation by staff 4 sent to the resident?s physician, dated 11/18/2021, stated that ?resident fell trying to get out of memory care?. The individualized service plan (ISP) for the resident, with a subsequent review/update of plan signed on 12/01/2021 by staff 1 and 2, does not address the resident?s care needs of the resident talking about going home, not having his wallet, looking for keys, packing all his stuff, stating he was leaving, and the resident?s fall due to trying to get out of memory care. 4. Incident report from staff 1 emailed to the licensing inspector (LI) on 12/27/2021 stated that ?On 12/23/2021 staff reported that resident was returned to the community by a Lynchburg Police Officer who reported that resident was observed walking on Merrell Rd [sic] in the direction of Longhorn Road [sic]. Resident was able to tell staff what happened and demonstrate how he was able to push four fingers under the lip of the door and pull the door open them [sic] proceeded to go through the main door. He further stated that once he exited the building he got turned around, walked down the driveway and up the street. Staff reported that resident was last seen approximately 4:30 AM where he was walking down the hall, which he does occasionally, all other times he spends in his room. At 4:46AM Community staff received a call from Lynchburg Police Department where inquiries were made as to whether or not we had a resident by the name of (resident).? Google maps shows that where the resident was found by the police officer is a 0.4 mile walk from the facility. 5. According to timeandate.com, the temperature for 12/23/2021 from 3:54AM to 4:54AM was between 27 degrees Fahrenheit and 26 degrees Fahrenheit.
Plan of Correction:	ISP revised to include interventions in behavior relating to elopement/exit seeking. Staff will sit with resident while he enjoys a cup of coffee, discuss his military career, call the daughter as needed or requested by resident with documenting on behaviors to be sure to implement interventions on ISP. Report to supervisor for further follow up with psych as needed ? DON/MCM with continue to monitor and provide oversite with behavioral documentation and follow up. First Fire notified of breech in Maglock. Tech was dispatched to community First Fire/Sprinkler in community completed repairs on system immediately ? doors monitored/checks monthly by company ongoing. Maintenance tech check doors weekly. Unit was staffed with 3 staff persons when census is 20. Updated recommendation will be forwarded to state inspector in the next 24-48 hours.
Standard #:	22VAC40-73-510-C
Description:	Based on resident record review, the facility failed to ensure efforts, which must be documented, were made by the assisted living facility to assist in ensuring that prescribed interventions are implemented, monitored, and evaluated for their effectiveness in addressing the resident?s mental health needs. EVIDENCE: 1. ?History and Physical Reports? by Collateral 2 , dated 10/19/2021, showed that resident 1 ?was brought into the ED by daughter with complaints of worsening behavioral disturbances including agitation, visual and auditory hallucinations and insomnia worsening over the past 2 months.? and ?Suicidal thoughts - Per daughter, patient has reported suicidal ideations with intent to shoot himself and `there are people trying to break into his house with his gun but currently denies any SI or HI?. ?Per psych, patient does not at suicide risk when family members are present but recommend suicide precautions and a sitter.? 2. Progress note by Collateral 3, dated 10/28/2021, stated ?Per his daughter patient had threatened to kill himself using his gun as he believed that people were attempting to break into his house. Patient had firearms in the house but ammunition was taken away by the family members. In the ER patient denied any active or passive suicidal ideations, stating that he would never hurt himself or anybody else. Patient was seen by psych services and deemed not at suicide risk when family members are present. Recommends suicide precautions and sitter.? 3. Psychiatric evaluation by Collateral 4 (signed by Collateral 5), dated 11/3/2021, stated that resident 1 was seen for ?Chief Complaint/ Nature of Presenting Problem: depression, psychosis, confusion and hallucinations?. 4. The record for resident 1 does not contain information that the resident is on suicide precautions or that the resident has a sitter. Interview with staff 1 on 01/18/2022 confirmed this information was accurate. 5. The licensing inspector was provided documentation from staff 1 on 01/19/2022 by Collateral 5 that "(resident) cleared by psych. No longer needs a sitter or suicide precautions. Note 1/19/22 stating this will be submitted within 24 to 48 hours of this date 1/19/22."
Plan of Correction:	Spoke with psych team psych service to clarify highlight plan of treatment changes in medications, speak directly with RCC/DON/MCM to ensure continuance of care and as prescribed ? Resident revaluated today by psych for clarification of needs for previous recommendations, suicidal ideation, sitter 1 on 1. Documentation to be rec?d by 20-36 hours Community will look at options to implement 10 bracelets ? discuss with family need for means of monitoring
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physicians or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, conditions or specific indications for administering each drug. EVIDENCE: The record for resident 1 contained two physicians? orders, dated 10/27/2021 and 01/05/2022, for the following medications: aspirin 81 mg, dorzolamide ophthalmic eye drops, finasteride, furosemide, metoprolol, metronidazole topical, mirtazapine, ramelteon, tamsulosin, and venlafaxine. Neither physicians? orders identified the diagnosis, condition, or specific indication for administering the medications.
Plan of Correction:	Continue to work diligently with RX to aid with having DX added. Express the urgency of having this added for compliance speak with attendings to add DX to all drugs orders within 60 days psych to add all DX to psychotropics within 60 days.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure the interior of the building was maintained in good repair. EVIDENCE: During a tour of the living room in the facility?s safe, secure unit on 01/05/2022, the licensing inspector (LI) observed that there were multiple areas of wallpaper that are peeling from the wall.
Plan of Correction:	Walls will be repaired and painted in completion in 60 days.
Standard #:	22VAC40-73-870-E
Description:	Based on observation, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, were kept clean and in good repair and condition. EVIDENCE: During a tour of the living room in the facility?s safe, secure unit on 01/05/2022, the licensing inspector (LI) observed that the chair and the couch in the living room contained multiple black stains.
Plan of Correction:	Furnishings to be replaced within the next 60 days.