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: May 26, 2022

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 inspector was on-site at the facility for each day of the inspection: 05/26/2022 8:45am until 2:00pm 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: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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. An exit meeting will be conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on review of resident records, the facility failed to ensure that the current disclosure state form was used for prospective residents. EVIDENCE: 1. The disclosure statement in the records for residents 1, 5 and 6 were noted to lack information on the facility emergency power source as required by this standard.
Plan of Correction:	Facility will begin using the VDSS disclosure form. ED will ensure that emergency power is listed on the disclosure form and not just in the contract.
Standard #:	22VAC40-73-210-G
Description:	Based on review of staff records, the facility failed to ensure documentation of the number of hours of training for staff. EVIDENCE: 1. The record for staff 3, date of hire 04/08/2021, did not contain documentation of the number of hours for all the training that the staff member had completed for the training year 04/08/2021 through 04/07/2022.
Plan of Correction:	The Business Office Manager or designee will ensure that training hours are listed on all future in-services. BOM will now add that to her auditing tool for future use.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that staff screenings for tuberculosis were completed in entirety on or within 7 days prior to the first day of work. EVIDENCE: 1. The record for staff person 2, hired on 04/20/2022 has documentation of a screening for tuberculosis that is lacking the date of the screening making it unclear if the screening was completed on or within 7 days prior to the first day of work at the facility.
Plan of Correction:	The Business Office Manager or designee will ensure dates are on all TB screening forms and will check for this before filing the screening in the employee record.
Standard #:	22VAC40-73-310-B
Description:	Based on review of resident records, the facility failed to ensure a documented interview occurred between the administrator or designee and the resident and their legal representative prior to or on the date of admission. EVIDENCE: 1. The record for resident 1, 5 and 6 did not contain documentation of an interview conducted with the resident and their legal representative prior to or on the date of these residents admission.
Plan of Correction:	The facility will begin using an interview form for each new admission. This will be added to the auditing tool used for all new admissions.
Standard #:	22VAC40-73-310-D
Description:	Based on review of resident records, the facility to insure that written assurance was provided to a resident at the time of their admission. EVIDENCE: 1. The record for resident 1, admitted on 03/14/2022, did not contain documentation that written assurance was provided to this resident at the time of their admission to the facility.
Plan of Correction:	The written assurance was completed before admission and was found after the inspection. The ED will ensure that all papers are filed in the record at time of admission. Facility does have a letter of written assurance that is used for each admission. An audit of resident records confirmed that written assurance was in each record.
Standard #:	22VAC40-73-440-A
Description:	Based on review of resident records and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) was updated when there was a significant change in the resident?s condition. EVIDENCE: 1. The individualized service plan (ISP) for resident 7, with an update of 05/03/2022, indicated that staff are to complete routine two hour checks on the resident due to disorientation. The UAI for resident 7, dated 02/15/2022, indicated that the resident is oriented. Interview with staff person 4 revealed that the resident is disoriented some spheres, some of the time to place and time meaning that the ISP is correct and the UAI was not updated as required.
Plan of Correction:	The Director of Nursing or designee will ensure that all changes in conditions will be updated on both the ISP and UAI. A chart review of all records will be performed to ensure compliance to this standard. Additionally, the ISP coordinator will be in-serviced and re-educated on this standard.