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 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

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, building and grounds and emergency preparedness. 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 #:	22VAC40-73-290-B
Complaint related:	Yes
Description:	Based on observations made during an on-site inspection conducted on 10/18/2021, the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. EVIDENCE: 1. The facility current person in charge posting was noted to lack the name of the current on-site person in charge on the day of inspection.
Plan of Correction:	Posting of staff member in charge will be updated daily by our concierge team for both 7am -7pm and 7pm-7am shifts. The posting will be displayed on the concierge counter at the front of the community.
Standard #:	22VAC40-73-610-B
Complaint related:	Yes
Description:	Based on observations made during an on-site inspection conducted on 10/18/2021, the facility failed to ensure that substitutions made to the lunch meal on 10/18/2021 was recorded on the posted menu. EVIDENCE: 1. The facility posted menu has documentation that grilled Italian subs with florentine soup or tomato an bacon sandwich and curry soup would be served as the lunch meal on10/18/2021. The lunch meal that was observed being served to residents in the dining room consisted of tomato soup, clam chowder, grilled cheese sandwich and salad.
Plan of Correction:	Dining Service Director will provide a staff in-service to re-educate dining service associates as to protocol for recording substitutions on the posted menu. DSD will create a binder to file menus with substitutions after the menu cycle is complete.
Standard #:	22VAC40-73-860-I
Complaint related:	Yes
Description:	Based on observations made during an on-site inspection conducted at the facility on 10/18/2021, the facility failed to ensure that all cleaning supplies were stored in a locked area. EVIDENCE: 1. The storage closet in the kitchen where cleaning supplies are stored was noted to be unlocked as the lock on the door was broken on the day of inspection. The storage closet is located by a door that leads directly to a hallway frequented by residents and this door into the kitchen was also noted to be unlocked.
Plan of Correction:	A new keyed/lockable handle set was placed on this door. Staff have been in-services on keeping this locked at all times, if there is not a staff member in the closet accessing supplies.
Standard #:	22VAC40-73-980-H
Complaint related:	Yes
Description:	Based on observations made of the facility emergency food supply during an on-site inspection conducted on 10/18/2021, the facility failed to ensure that a 48 hour supply of emergency food was on-site at the facility. EVIDENCE: 1. The facility was noted to have a total of 64 residents in care on the day of inspection with 44 of those residents being assisted living level of care. The facility 48 hour on-site emergency food supply was observed in the presence of staff persons 2, 3 and collateral witness 1. The supply was noted to lack enough items to provide breakfast, lunch and dinner as well as snacks to 64 residents for the required 48 hours. Staff were unable to determine what appliances (refrigerator or freezers) is run by the facility generator in the event of a power outage to be able to consider food being stored in these appliances.
Plan of Correction:	Emergency food supply was ordered on 10/18/2021 and delivered by 10/22/21. Supply is in stock room and labeled as designated emergency supply.