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: July 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/08/2022 10:00AM until 1:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/21/2022 regarding allegations in the area of resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on resident record review, staff documentation and staff interview, the facility failed to ensure that prior to admission to a safe, secure environment, the resident was assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: 1. Staff 1 faxed the regional licensing office (the licensing inspector (LI) of record for the facility) on 06/21/2022 to inform the LI of the following information regarding resident 1: ?On June 20, 2022, (resident 1) was observed in the front entrance area of the facility. (Resident 1) was redirected and assisted back into the facility. A head to toe assessment was completed on (resident 1) and no abnormalities were noted. (Resident 1) supervision was modified and he was placed on our secured unit.? 2. The record for resident 1 contained the following staff notes: 06/20/2022 at 7:36PM; ?spoke with POA to let him know resident got out of building and was found at end of roadway, resident was put in memory care for night for safety precautions?, 06/20/2022 at 9:04PM; ?place resident in special care unit for safety concerns.?, and 06/21/2022 at 4:20AM; ?resident was placed in Memory Care for precautions?. 3. The ?Assessment of Serious Cognitive Impairment? was not completed by Collateral 1 until 06/21/2022 therefore meaning that the resident was placed in the facility?s safe, secure unit prior to the assessment being conducted. In addition, the ?Assessment of Serious Cognitive Impairment? stated that the resident is able to recognize danger and protect his/her own safety and welfare.
Plan of Correction:	- The facility will ensure that prior to admission to a safe, secure environment, the resident will be assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. -The ?Assessment of Serious Cognitive Impairment? was corrected by the physician for resident 1. - All of the residents chart in Memory Support will be reviewed to ensure the Assessment of Serious Cognitive Impairment is completed appropriately in the file. The `Assessment of Cognitive Impairment? will be completed prior to the resident be placed on facility?s safe, secure unit. - The Designee will review all paperwork prior to the admission to the facility?s safe, secure unity.