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: June 6, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 8:00AM until 3:45PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: breakfast, noon-time meal, morning medication pass and an audit of medication carts An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment. EVIDENCE: The records for staff persons 3 and 4, both hired on 03/08/2023, do not contain documentation that these employees have received certification in first aid as of the day of inspection.
Plan of Correction:	Executive Director/Designee and/or Business Office Coordinator will ensure all new hires have adequate certification within 60 days of employment. Business Office Coordinator has set in place a tickler system to review all new hires (within 60 days of employment) have completed first aid certification; and annual reminders for staff to renew certification. Tickler system status will be discussed during daily management standup meeting. Person Responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director/Designee and/or Business Office Coordinator/Designee
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review, the facility failed to ensure that aggressive behavior training for direct care staff included, at a minimum, information, demonstration, and practical experience in self- protection and in the prevention and de-escalation of aggressive behavior and that training was provided by a qualified health professional as required in 22VAC40-93-270-3-b. EVIDENCE: 1. The records for staff persons 3 and 4 contain documentation of on-line training (Collins) training for behavior management strategies for cognitively impaired residents. The training does not include demonstration and does not have documentation of a qualified health professional who taught the training.
Plan of Correction:	Executive Director/Designee and/or Business Office Coordinator will audit staff training files and ensure that all staff have completed an in-service on Aggressive/Combative Behavior. Director of Resident Care and/or Certified Dementia Practitioner/Designee will conduct demonstrated training for all new hires and annually for all staff. Business Office Coordinator and/or Designee will maintain recordkeeping of all staff training. Person Responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director, Resident Care Director/Nurse, and/or Business Office Coordinator
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to ensure that a fall risk rating was completed annually for residents who are assessed as assisted living level of care on uniform assessment instruments (UAI). EVIDENCE: The UAI dated 03/08/2023 in the record for resident 5 has documentation that the resident is assessed as assisted living level of care. The last fall risk rating completed for this resident was dated 11/18/2021.
Plan of Correction:	Executive Director and/or Designee will ensure Clinical Members responsible for review and updating fall risk ratings have been educated on appropriate process and regulatory guidelines. Resident Care Director and/or Designee will review all fall reports to ensure fall risk ratings are updated accordingly. Executive Director/Designee, will conduct a monthly resident chart audit (3-4 charts); randomly selected residents who have experienced falls to ensure continued compliance. Person Responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Director of Resident Care and/or Designee
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interviews, the facility failed to ensure that uniform assessment instruments (UAIs) contain all required components. EVIDENCE: 1. The UAI for resident 1, with a reassessment date of 03/30/2023, indicates on page 2 that the resident is disoriented some spheres, some of the time; however, the spheres affected are not included. Interview with staff 8 revealed that the spheres affected are place and time. Also, the UAI for resident 1 was not signed and dated by the administrator or designee on page 2. 2. The UAI for resident 2, dated 05/13/2023, contains documentation that the resident does not require any assistance with eating/feeding. The record for resident 2 has documentation of a physician order, dated 01/31/2023, for a mechanical soft/ground meat diet. Interview with staff persons 1 and 6 expressed that resident 2 is receiving a mechanical soft/ground meat diet, which is considered mechanical assistance with this ADL need. 3. The UAI for resident 3, with a reassessment date of 01/24/2023, indicates on page 2 that the resident is disoriented some spheres, all the time; however, interview with staff 8 revealed that the resident is disoriented to all spheres all the time. Also, the UAI for resident 3 was not signed and dated by the administrator or designee on page 2 to reflect the reassessment on 01/24/2023. 4. The UAI for resident 6, dated 01/19/2023, indicates that the resident is disoriented to some spheres all of the time to place, time and situation; however, the ISP for the resident, dated 02/16/2023, indicates that the resident is disoriented to some spheres, some of the time. Interview with staff 8 revealed that the ISP is correct and the UAI is incorrect.
Plan of Correction:	Facility will ensure that individualized service plans (UAIs) for residents contained all required components. Executive Director and/or Designee will conduct a weekly audit of 2-5 resident UAIs, until audit complete. Any residents with significant change in condition will be updated on both UAI and ISP. Director of Resident Care and/or Designee will implement a monitoring/tickler system to ensure any future UAIs and ISPs are completed within 30 days of admission, annually, and/or when resident experiences a significant change in condition. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Director of Resident Care and/or Designee
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interviews, the facility failed to ensure that individualized service plans (ISPs) for residents contained all required components. EVIDENCE: 1. The ISP for resident 1, dated 03/31/2023, indicates that the resident requires mechanical assistance with toileting and transferring; however, the uniform assessment instrument (UAI) for resident 1, with a reassessment date of 03/30/2023, indicates that the resident does not require any assistance with toileting and transferring. Interview with staff 8 revealed that the UAI is correct and the ISP is incorrect. 2. The UAI for resident 5, dated 03/08/2023, contains documentation that the resident requires supervision with toileting. Interview with staff 5 expressed that resident 5 does require this ADL need but the ISP dated 03/08/2023 does not address resident 5?s toileting supervision needs. 3. The ISP for resident 6, dated 02/16/2023, indicates that the resident requires physical assistance with dressing; however, the UAI for the resident, dated 01/09/2023, indicates that the resident requires physical assistance and mechanical assistance with dressing. Interview with staff 8 revealed that the UAI is correct and the ISP is incorrect.
Plan of Correction:	Facility will ensure that individualized service plans (ISPs) for residents contain all required components. Executive Director and/or Designee will conduct weekly resident charts audits (2-5 resident ISPs), until audit complete. Any residents with significant change in condition will be updated on both UAI and ISP. Director of Resident Care and/or Designee will implement a monitoring/tickler system to ensure any future UAIs and ISPs are completed within 30 days of admission, annually, and/or when resident experiences a significant change in condition. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Director of Resident Care and/or Designee
Standard #:	22VAC40-73-610-D
Description:	Based on resident record review, observation, and staff interviews, the facility failed to ensure that a diet that is prescribed for a resident by his physician or other prescriber is prepared and served according to the physician?s or other prescriber?s orders. EVIDENCE: 1. The record for resident 3 contains a document from Collateral 1, dated 04/07/2023, that the resident has been diagnosed with gastroparesis and that due to this diagnosis an individual?s stomach empties very slowly because the nerves to the stomach are damaged or do not work properly which can cause bloating, nausea, vomiting or feeling full after eating only a small amount of food. 2. The signed document, dated 04/07/2023, by the nurse practitioner who is employed by Collateral 1 states that it is recommended for the resident to have small meals five times daily instead of three larger meals and one day a week the resident should be on a mostly liquid diet to help irrigate the stomach. In addition, the resident?s individualized service plan (ISP), dated 01/24/2023, includes that the resident will receive a soft diet with no bread and five small meals per day and snacks. 3. During on-site inspection on 06/06/2023, interview with staff 7 revealed that the white board in the facility?s kitchen is used by staff to know which residents have a special diet; however, the white board did not indicate the aforementioned diet for resident 3. When the licensing inspector (LI) asked staff 7 is she was aware of the diet for resident 3, staff 7 indicated that she was not aware of the diet.
Plan of Correction:	Facility will ensure that a diet that is prescribed for a resident by their physician or other prescriber is prepared and served according to the physician?s or other prescriber?s orders. Director of Resident Care and/or Designee will audit and review all resident diet orders with Dietary Manager and/or Designee to ensure accuracy. Dietary Manager and/or Designee will prepare and serve resident meals according to their diet orders prescribed by their physician?s or other prescriber?s orders. Executive Director/Administrator and/or Designee will monitor for accuracy during regular rounds within the dining room during meal times. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee and Director of Resident Care and/or Designee
Standard #:	22VAC40-73-650-C
Description:	Based on resident record review, the facility failed to ensure that physician orders contained documentation of the individual who took the order. EVIDENCE: The record for resident 4 has an order written on a facility physician order form dated 06/01/2023 for ?D/C cardiac diet. Change to regular no added salt diet?. The form does not have documentation of the individual who took the order.
Plan of Correction:	Executive Director and/or Designee will ensure that physician orders contained documentation of the individual who took the order. Resident Care Director and/or Designee will review with Executive Director and/or Dietary Manager all new physician orders for accuracy. Director of Resident Care and/or Designee will then sign-off on resident diet orders and submit to Dietary Manager and/or Designee to reference. Person Responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Director of Resident Care and/or Designee
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber was provided according to his instructions and documented. EVIDENCE: 1. The record for resident 4 has documentation of a physician order dated 06/01/2023 for foley care every shift. The June 2023 medication administration record (MAR) for resident 4 does not have documentation of foley care being completed every shift from 06/01/2023 through 06/06/2023. 2. The record for resident 8 contains a physician?s order, dated 09/16/2022, to check the resident?s oxygen level every shift (three times daily) to maintain oxygen stats above 95 on room air and for oxygen at two liters continuous via nasal cannula to be administered as needed for when the resident?s oxygen is below 95. 3. The May 2023 medication administration record (MAR) for resident 8 contains multiple days in which the resident?s oxygen level was recorded below 95 indicating that oxygen should have been administered to the resident; however, the May 2023 MAR does not include documentation that the resident was administered oxygen by staff on these days.
Plan of Correction:	Facility will ensure that medical procedures or treatments ordered by a physician or other prescriber for a resident are provided according to instructions and documented. Executive Director/Designee and Resident Care Director/Nurse will ensure that all RMA?s attend an in-service on accurate medication administration and treatments. Resident Care Director/Designee and/or Resident Care Coordinator will conduct weekly audits and medication pass observations to ensure proper compliance with physician orders are being followed as prescribed in comparison with what being recorded in the electronic medication record. Person Responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Director of Resident Care and/or Designee
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, an audit of the facility?s safe, secure unit medication cart and staff interview, the facility failed to ensure that a medication administration record (MAR) for a resident contained all required components. EVIDENCE: 1. The June 2023 MAR for resident 7 indicates that the resident is prescribed Polyethylene Glycol powder daily at 7:00AM. During the licensing inspector?s (LI) observation of the morning medication pass for resident 7 that was conducted by staff 2 on 06/06/2023, staff 2 did not administer Polyethylene Glycol to the resident; however, the June 2023 MAR for the resident indicates that this medication was administered to the resident by staff 2 at 7:00AM on 06/06/2023. 2. During an audit of the facility?s safe, secure unit?s medication cart by two LIs, Polyethylene Glycol was not observed in the medication cart for resident 7. Interview with staff 2 revealed that there was no Polyethylene Glycol for the resident and that even though she documented that she administered it to the resident at 7:00AM on 06/06/2023 she did not administer it and it should be documented that it was not available in the facility for resident 7.
Plan of Correction:	Facility will ensure that all prescribed medications listed on resident?s MAR, will include all required components. Director of Resident Care and/or Designee will conduct an audit and ensure all prescribed medications listed on resident?s MAR contained all required components. Director of Resident Care and/or Designee will implement a monitoring/tickler system to ensure all prescribed medications listed on resident?s MAR contained all required components. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Director of Resident Care and/or Designee
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good condition and keep clean. EVIDENCE: The carpet in room 108 was noted to have multiple stains throughout the room. Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: The storage closet on the left in the activity room was noted to be unlocked on the day of inspection and contained a bottle of Studio Selections Nail Polish Remover sitting out on a shelf in the closet.
Plan of Correction:	Executive Director and/or Designee will conduct an all staff in-service to review and emphasize the importance of adherence to standard 860-I. Maintenance Director has adjusted all storage closet door knobs to automatically lock when closed. Maintenance Director and/or Designee will conduct regular rounds within the facility to ensure storage doors are locked at all times. Person Responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good condition and keep clean. EVIDENCE: The carpet in room 108 was noted to have multiple stains throughout the room.
Plan of Correction:	Executive Director and/or Designee will ensure carpets in all areas of the facility are on a set cleaning schedule; and repairs and/or replacement needs will be addressed to maintain compliance. Housekeeping Manager and/or Designee will conduct weekly walk-through of facility and report any repair and/or carpet replacement needs to the Executive Director and/or Maintenance Manager. Maintenance Manager and/or Designee will check Maintenance Logs daily for preventative maintenance needs that must be addressed within the facility. Person Responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff persons 4, 10 and 13 were hired 03/08/2023, staff person 9 was hired 11/01/2022, staff person 3 was hired 03/01/2023, and staff persons 12 and 14 were hired 03/27/2023. The criminal history report documents provided for these staff persons indicate that all requests were not received by the Virginia State Police (VSP) until 05/02/2023 indicating that the facility did not receive the reports for these staff persons on or prior to the 30th day of employment. 2. Interview with staff person 6 during on- site inspection on 06/06/2023 revealed that the facility could not say that the aforementioned staff persons worked under the direct supervision of another employee for whom a background check had been completed until the criminal history record reports were obtained for these staff persons. 3. The record for staff person 11 did not contain the results of a criminal record history report for this staff person and the results of one were not provided to the licensing inspector as of 06/12/2023.
Plan of Correction:	Facility will ensure the criminal history record report is obtained on or prior to the 30th day of employment for each staff person. BOC and/or Designee will audit staff files to ensure each staff file contains documentation of a criminal history record report; that has been obtained within the regulatory timeframe. Executive Director and/or Designee will review audit documentation. Director of Resident Care and/or Designee will complete Supervisory Assignment Sheets for any new hires, awaiting criminal background report, who are working shifts within the first 30 days of employment. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee and Business Office Coordinator and/or Designee