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 18, 2024

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/18/2024 07:50 to 3:50pm 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: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that a documented interview was completed between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any. EVIDENCE: 1. The record for resident 5, admission date 4/15/2024, did not contain a documented interview. 2. During an interview on 4/18/2024 with the licensing inspector (LI) and staff person 4, staff person 4 confirmed the record that a documented interview was not completed.
Plan of Correction:	RCD/ISP Coordinator and/or Designee will complete note describing interview of prospective resident at time of Uniform Assessment Instrument (UAI) completion prior to admission. Note will be located in EMAR system and/or physical copy attached to physical copy of Uniform Assessment Instrument. Ongoing
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included the dosage. EVIDENCE: 1. The record for resident 7 has a physician?s order dated 1/2/2024 for Novolog 100 Unit/ML solution pen injector, inject as per sliding scale; if 0 ? 149 = 0, 150 ? 200 = 2; 201- 250 = 4; 251 ? 300 = 6; 301 ? 350 = 8; greater than 400 notify MD; 351 ? 400 = 10 subcutaneously after meals and at bedtime for DM. 2. The April 2024 MAR in the record for resident 7 has documentation that the resident?s blood sugar was 155 on 4/2, 161 on 4/3, 165 on 4/4 at 12:30pm, 166 on 4/2, 180 on 4/7, 176 on 4/9 at 5:30pm, and 151 on 4/2, 196 on 4/9 at bedtime of which the residents blood sugar fell within parameter to receive sliding scale insulin coverage. The MAR does not have documentation that units were given for the Novolog 100Unit/ml for any of these blood sugars or of any injection sites. 3. During an interview on 4/18/2024 with the licensing inspector (LI) and staff person 6, staff person 6 confirmed the MAR did not have documentation of the units given.
Plan of Correction:	RCD and/or Designee will audit and review medication dashboard weekly. Staff educated on proper documentation for insulin administration. Ongoing
Standard #:	22VAC40-73-680-M
Description:	Based on resident record review and staff interview, the facility failed to ensure the medications ordered for PRN administration shall be available for a resident. EVIDENCE: 1. The record for resident 1 has a physician?s order dated 4/2/2024 for Anti-Diarrheal 2mg Caplet ? Take 1 tablet by mouth as needed after each loose stool ? DNE 8tabs/24hrs and Benzonatate 100 mg capsule ? take one capsule by mouth 3 times a day as needed for cough. 2. During a medication cart review on 4/18/2024 with the licensing inspector and staff person 3, staff person 3 confirmed the medications were not in the cart and available for the resident.
Plan of Correction:	RCD and/or Designee will ensure all PRN medications are available, properly labeled for the specific resident, and properly stored at the facility. Ongoing
Standard #:	22VAC40-73-950-E
Description:	Based on facility record review and staff interview, the facility failed to ensure a semi-annual review on the emergency preparedness and response plan for all residents, with emphasis placed on an individual's respective responsibilities. EVIDENCE: 1. On 4/18/2024, The licensing inspector (LI) requested to review documentation of the semi-annual review on the emergency preparedness and response plan with all residents. The facility binder that was identified as the survey readiness book did not have documentation that a semi-annual review was completed with all residents. 2. During an interview on 4/18/2024 with the LI and staff person 4, staff person 4 confirmed that the semi-annual review on the emergency preparedness and response plan with all residents had not been completed.
Plan of Correction:	ED and/or Designee will ensure that a written record of biannual emergency preparedness review for all residents be completed and filed in state survey readiness file