VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bentley Commons at Lynchburg
1604 Graves Mill Road
Lynchburg, VA 24502
(434) 316-0207

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Oct. 18, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated complaint inspection was initiated on 10/18/2021 and concluded on 11/03/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The licensing inspector conducted an on-site observation at the facility on 10/18/2021 and documentation was requested to be emailed to the LI during the on-site inspection. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations issued can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on a review of facility documentation, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. A facility incident report dated 9/21/2021 for resident 3 has documentation of alleged abuse and that resident 3 indicated that staff was rough when caring for her. Bruising was noted on resident 3's bilateral arms and right hand. The facility did not notify the regional licensing office of this incident until 10/8/2021,17 days after the incident occurred.
Plan of Correction:	Review of 22VAC40-73-70 regarding incident reporting and items that require reporting to DSS within 24 hours will be completed by the Executive Director and Resident Care Director. Executive Director and Resident Care Director will hold in-service to review with all department managers and care supervisors to ensure they understand reportable incidents and that they must notify a supervisor of any such incident at time of incident, or at time they learn of incident.
Standard #:	22VAC40-73-130-A
Complaint related:	Yes
Description:	Based on review of resident records, facility documentation and interviews with staff, the facility failed to ensure that mandated reporting occurred as per 63.2-1606 of the Code of Virginia. EVIDENCE: 1. Documentation in a written warning dated 9/21/2021 and several staff written interviews expressed that residents 1 through 5 had made complaints in regards to staff person 1's treatment towards them between 9/5/2021 and 9/21/2021. An incident report dated 9/21/2021 for resident 3 has documentation of alleged abuse and that resident 3 indicated that staff was rough when caring for her. Bruising was noted on resident 3's bilateral arms and right hand. In a phone interview with collateral witness 1 it was expressed that these complaints of suspected abuse or neglect were not reported to the local Adult Protective Agency as required by 63.2-1606 of the Code of Virginia.
Plan of Correction:	Review of 63.2-1606 of the code of Virginia and 22VAC40-73-130-A will be completed by the Executive Director and Resident Care Director. Executive Director and Resident Care Director will hold in-service to review with all department managers and care supervisors to ensure they understand incidents that require mandated reporting and that they must notify a supervisor of any such incident at time of incident, or at time they learn of incident.