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: March 3, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 03/03/2023 9:50AM through 11:35AM 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 01/23/2023 regarding allegations in the area of resident care and related services. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also 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 #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) was completed at least annually. EVIDENCE: The most recent UAI in the record for resident 1 during on-site inspection on 03/03/2023 was dated 10/21/2021. Interview with staff 5 confirmed this was accurate.
Plan of Correction:	Facility will ensure all resident?s uniform assessment instrument (UAI) was completed at least annually. Executive Director and/or Designee will audit existing all resident charts. Resident Care Coordinator and/or Memory Care Manager will implement a monitoring/tickler system for all residents in the community for UAI updating and/or renewal. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or DRC and/or Designee
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months. EVIDENCE: The most recent ISP in the record for resident 1 during on-site inspection on 03/03/2023 was reviewed and updated by the facility and signed by the resident on 11/27/2021. Interview with staff 5 confirmed this was accurate.
Plan of Correction:	Facility will ensure all resident?s comprehensive individualized service plans (ISP) are reviewed and updated at least once every 12 months. Executive Director and/or Designee will audit existing all resident charts. Resident Care Coordinator and/or Memory Care Manager will implement a monitoring/tickler system for all residents in the community for ISP updating and/or renewal.Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or DRC and/or Designee
Standard #:	22VAC40-73-670-1
Description:	Based on document review, resident record review and staff interview, the facility failed to ensure each staff person who administers medication is licensed by the Commonwealth of Virginia or is registered with the Virginia Board of Nursing as a medication aide. EVIDENCE: 1. On 01/23/2023, the licensing inspector (LI) received an email from staff 3 reporting that on 01/21/2023 staff 1, who is a registered medication aide (RMA), gave staff 2, who is not licensed to administer medications, the 9:00AM dose of crushed medications for residents 1 and 2 so that staff 2 could place the crushed medications in residents 1 and resident 2?s coffee mugs for resident 1 and 2 to take. 2. At 8:30AM on 01/21/2023, staff 2 reported to staff 4 that she had put the medications in the coffee mugs for residents 1 and 2 but that resident 1 had consumed the coffee mug that contained resident 2?s medications which contained the following medications: aspirin 81MG, Atenolol 25MG, Levetiracetam 250MG, Lisinopril 5MG, Memantine 10MG, Quetiapine 80MG (liquid medication), and Tamsulosin 0.4MG.
Plan of Correction:	Facility will ensure each staff person who administers medication is licensed by the Commonwealth of Virginia or is registered with the Virginia Board of Nursing as a medication aide. The Administrator, Director of Nursing, Resident Care Coordinator, and/or Licensed Designee shall regularly monitor medication passes to ensure proper medication administration procedures are followed and that no non-licensed staff member are allowed to administer medications to residents. The Administrator, Director of Nursing, Resident Care Coordinator, and/or Licensed Designee shall ensure that all medications given to resident has a valid physician order. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or DRC and/or Designee
Standard #:	22VAC40-73-680-B
Description:	Based on document review, resident record review and staff interview, the facility failed to ensure medications shall be removed from thepharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person. EVIDENCE: 1. On 01/23/2023, the licensing inspector (LI) received an email from staff 3 reporting that on 01/21/2023 staff 4 was made aware by staff 2 of the following information: on 01/21/2023 staff 1, who is a registered medication aide (RMA), gave the 9:00AM dose of crushed medications for resident 1 and resident 2 to staff 2 to administer to residents 1 and 2. 2. Staff 2 informed staff 3 that she put the crushed medications in the coffee mugs for residents 1 and 2 as she was instructed by staff 1 to do so.
Plan of Correction:	Facility will ensure all resident?s medications shall be removed from the pharmacy container, Facility will ensure all resident?s medications shall be removed from the pharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person. Resident Care Coordinator and/or Memory Care Manager will monitor for proper medication administration procedures during their daily rounds. Resident Care Coordinator and/or Memory Care Manager will in-service Direct Care Staff; re-educating them to maintain medications in a pharmacy issued container at all times up until the point of assisting or administering them to residents. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or DRC and/or Designee
Standard #:	22VAC40-73-680-D
Description:	Based on document review, resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing (VBON). EVIDENCE: 1. Documentation provided by staff 3 and interview with staff 3 indicated that on 01/21/2023 staff 1 had crushed the 9:00AM dose of medications for residents 1 and 2 and then the crushed medications had been placed in coffee by staff 2 for both residents 1 and 2; however, during on-site inspection on 03/03/2023, the records for residents 1 and 2 did not contain a physician?s order that the residents? medications can be crushed and placed in coffee. In addition, the record for resident 2 contained a physician?s order, dated 03/23/2022, for the resident to take medications whole. 2. Also, the Medication Aide Curriculum for Registered Medication Aides, revised by the VBON in 2022, indicates on page 38 that medication is not to be mixed with food or liquids without a written order.
Plan of Correction:	Facility will ensure all resident?s medications were administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing (VBON). Director of Nursing, Resident Care Coordinator, Memory Care Manager, and/or Designee/Person in Charge will review paperwork for new or changed orders upon admission, physician appointment/visit, hospital/ER return. Designee/Person in Charge will follow facility management plan policy on new orders and the approval process. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or DRC and/or Designee