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: April 25, 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 inspector was on-site at the facility for each day of the inspection: 04/25/2023 9:00am until 3:00pm 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: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that all direct care staff attended at least 18 hours of training annually. EVIDENCE: 1. The record for staff person 1, hired on 02/17/2017, did not include documentation that the staff person had at least 18 hours of annual training from 02/17/2022 through 02/17/2023. 2. The record for staff person 3, hired on 01/17/2019, did not include documentation that the staff person had at least 18 hours of annual training from 01/17/2022 through 01/17/2023. 3. Interviews with staff persons 5 and 7 confirmed that this is accurate.
Plan of Correction:	Director of Business Administration will audit training records for all staff monthly, utilizing online training interface. In-Person Trainings, led by qualified individuals and/or licensed health care professionals will be scheduled by DBA, Resident Care Director, or Designee, throughout the year to ensure compliance with regulations in which virtual training does not meet training requirements. Ongoing.
Standard #:	22VAC40-73-250-D
Description:	Based of staff record review, the facility failed to ensure that staff received a screening for tuberculosis on or within 7 days prior to the first day of work. EVIDENCE: 1. The record for staff person 2, whose first day of work was 10/25/2022, has documentation that a screening for tuberculosis for not completed until 10/27/2022.
Plan of Correction:	DBA will ensure all new hires are in compliance with screenings for tuberculosis on or within 7 days prior to the first day of work. Ongoing
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure that all direct care staff received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff person 4, hired on 10/13/2022, has documentation that this employee did not receive certification in first aid until 04/03/2023.
Plan of Correction:	DBA, RCD, and/or Executive Director will ensure documentation of first aid certification of all direct care staff is current and up to date at time of hire. If first aid certification has lapsed prior to date of hire, first aid training will be scheduled and completed within first 60 days of employment. Ongoing.
Standard #:	22VAC40-73-270-4
Description:	Based on staff record review and staff interview, the facility failed to ensure a refresher training for all direct care staff was provided at least annually or more often as needed for facilities that accept, or have in care, residents who are or who may be aggressive. EVIDENCE: 1. The record for resident 5 contained a staff note, dated 02/14/2023, that the resident was very agitated and confused the whole day, and an additional staff note, dated 02/22/2023, stated that the resident was agitated. Also, the record for resident 8 contained a staff note, dated 01/11/2023, that the resident was very combative with staff on the 11:00PM ? 7:00AM shift and staff had difficulty changing the resident?s soiled brief and the resident was calling out the name of staff and kicking. 2. The records for staff persons 1 and 2 do not have documentation that these individuals have had annual training for residents with aggressive behaviors. Interview with staff 5 and 7 confirmed that this is accurate.
Plan of Correction:	ED, RCD, and DBA will establish training schedule for face to face annual training for all direct care staff led by licensed health professional for compliance with state regulations on aggressive behaviors. Ongoing.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that within the 30 days preceding admission, a person had a physical examination by an independent physician that contained all required components. EVIDENCE: 1. Resident 5 was admitted to the facility on 12/19/2022. The report of resident physical examination in the record for the resident did not include the following information on page 1: the date of examination and the resident?s height weight and blood pressure. Page 3 of the examination was dated 12/20/2022 and the Virginia Tuberculosis (TB) risk assessment was dated 12/20/2022. There was no documentation provided during on-site inspection that the physical examination for the resident was conducted within 30 days preceding the admission of the resident.
Plan of Correction:	Director of Community Relations will ensure that all resident physical examinations and screening and/or testing for tuberculosis are complete prior to admission into the facility. Resident physical examinations will be audited by RCD and/or ED prior to admission into the facility. Ongoing.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that prior to or at the time of admission to an assisted living facility all required resident personal and social information was obtained. EVIDENCE: 1. The resident-personal/social data sheet for resident 3, admitted 02/07/2023, did not contain the following information for the resident: admission date, allergies, and interests/hobbies. 2. The resident-personal/social data sheet for resident 4, admitted 03/07/2023, did not contain information on resident allergies, lifetime vocation/career and current behavioral and social functioning including strength and problems. 3. The resident-personal/social data sheet for resident 6, admitted 02/14/2023, did not contain information on resident allergies, interest/hobbies, lifetime vocation/career, information on advance directives, DNR or organ donation if applicable.
Plan of Correction:	DCR and/or ED will ensure that all fields of resident personal/social data sheet are fully completed prior to or at date of admission. Ongoing.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) were completed as required. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 04/10/2023, indicates that the resident requires supervision human help and mechanical help with transferring; however, the ISP for the resident, dated 04/10/2023, indicates that the resident requires physical assistance human help of one nursing staff and mechanical help with transferring. Interview with staff 7 revealed that the UAI is correct, and the ISP is incorrect. 2. The most recent fall risk tool, dated 01/22/2023, in the record for resident 8 indicates that the resident has had 10 falls in the last six months and has a total score of 13. During interview with staff 7, staff 7 confirmed that this would identify the resident as a high fall risk; however, the resident?s ISP, recently updated 02/06/2023, does not indicate that the resident is a high fall risk. 3. The ISP for resident 8, recently updated 02/06/2023, indicates that the resident started receiving wound care two times weekly to treat open areas on the resident?s left buttock on 01/19/2023. When staff 7 was asked for wound care notes during the on-site inspection regarding this service, staff 7 revealed that the resident is no longer receiving wound care and indicated that the resident?s ISP needs to be updated to reflect that wound care has been discontinued for the resident. 4. The record for resident 6, admitted on 02/14/2023, has documentation of the resident falling on 03/14/2023, 03/26/2023 and 04/12/2023. A physician order dated 04/18/2023 was noted for a physical and occupational therapy evaluation. The ISP dated 04/13/2023 in the record for resident 6 does not address these identified needs.
Plan of Correction:	Individualized Service Plan Coordinator and/or ISP Certified Designee as assigned by RCD will ensure all Individualized Service Plans reflect accurate information as provided by Uniform Assessment Instrument, completed by UAI-certified personnel. Ongoing.
Standard #:	22VAC40-73-560-E
Description:	Based on resident record review, the facility failed to ensure that resident records were kept current. EVIDENCE: 1. The record for resident 6 has documentation that the resident is receiving regular routine wound care from a home health agency. The last documentation of home health notes to include documentation of wound care being completed in the record for resident 6 was dated 03/26/2023.
Plan of Correction:	RCD and/or Designee will ensure that any Home Health Agency providing care to residents in the facility provide documentation and updates from their visit/services provided. Resident/Responsible Parties will be notified by staff for non-compliance with the recommendation that services be performed by a Home Health Agency that will ensure compliance with Department of Social Services Regulations. Ongoing.
Standard #:	22VAC40-73-660-B
Description:	Based on observation during a tour of the physical plant and resident record review, the facility failed to ensure that for a resident that is capable of self-administering medication that the resident?s medication is kept in an out-of-sight place in the resident?s room and stored so that the medication and any dietary supplements are not accessible to other residents. EVIDENCE: 1. The report of resident physical examination in the record for resident 9, dated 08/01/2022, and the uniform assessment instrument (UAI), dated 08/11/2022, both indicate that resident 9 is capable of self-administering medications. Interview with staff 5 and 7 indicated that this is accurate. 1. At approximately 10:06AM during on-site inspection, it was noted by two licensing inspectors (LIs) that the door to resident 9?s room was unlocked, and the resident was not present in the room. The LIs observed that medications in resident 9?s room were not stored in an out-of-sight place as a small plastic cup with two loose pills and a bottle of Ciprofloxacin Ophthalmic solution 0.3% eye drops were observed sitting out on the kitchen counter. Also, the two LIs observed a pill box with multiple pills in the Wednesday and Thursday sections of the pill box sitting out on the bed.
Plan of Correction:	All Residents will be encouraged to keep entry doors to their apartments locked when not in their residences. Residents that have orders for self-administration of medications that choose not to keep their residence entry doors secured will be instructed in writing that all medications must be stored in an out-of-sight location and not accessible to other residents. Ongoing.
Standard #:	22VAC40-73-680-D
Description:	Based on observations of the facility medication carts and resident medication administration records (MARs), the facility failed to ensure that medications administered were consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The record for resident 10 has a physician order for the administration of Victoza 1.8ml sub-q at bedtime for DM. This medication is a non-insulin injection. 2. The record for resident 11 has a physician order for Ozempic 0.5mg sub-q every Saturday for DM. This medication is a non-insulin injection. 3. The April 2023 MARs for residents 10 and 11 have documentation of staff initials who are RMA?s for the administration of these medications. 4. Page 53 of the current 68 hour registered medication aide curriculum revised in 2022 has documentation that ?Non-insulin injections a. Medication aides may not administer pursuant to 18VAC90-60-110(B)(5)?.
Plan of Correction:	RCD and/or Designee will contact Resident?s Prescribing Physicians for new orders to ensure compliance with regulation 18VAC90-60-110(B)(5) on Non-Insulin Injections. I Ongoing.