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 15, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/15/2024 10:30am to 12:08pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/7/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 95 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-470-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure a resident's need for skilled nursing treatments within the facility was met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse. EVIDENCE: 1. The record for resident 1 has a physicians order dated 5/3/2024 with documentation for Wound Care due to a procedure performed on 5/3/2024 that requires follow up wound care. Keep the bandage on the wound for 24 hours. Keep bandage dry and clean. Do not get it wet while bathing. After 24 hours, remove the bandage. Clean the wound gently while bathing with soap and water. Then, apply a small amount of Vaseline and recover it with a Band Aid or other clean bandages. Repeat this once/day until the scab has fallen off or for 4 weeks. 2. The record for resident 1 has a subsequent physicans order dated 5/3/2024, with clarification made on 5/8/2024, with documentation for Bandage Care due to a procedure performed that requires bandage care. Keep the bandage on the site left forearm for 24 hours. Keep bandage dry and clean. Do not get it wet while bathing. After 24 hours, remove the bandage. Clean the site daily gently while bathing with soap and water. Then, apply a small amount of Vaseline and recover it with a Band Aid or other clean bandages. Repeat this once/day until 4 weeks. 3. The May 2024 Medication Passing Detail has documentation of staff person?s 3 initials on 5/4, 5/5, 5/6, 5/8, 5/9, 5/10, 5/13, and 5/14, staff person?s 4 initials on 5/7, and staff person?s 5 initials on 5/11 and 5/12 for completion of these treatments. The May 2024 Medication Administration Record has documentation that staff person 3,4, and 5 are Registered Medication Aides (RMA) however this treatment should have been completed by a licensed healthcare provider. 4. During an interview with one licensing inspector and staff person 1 on 5/15/2024, staff person 1 disclosed they requested clarification from the prescriber for the order to be changed to bandage care due to RMA not having the skill set to assess wounds.
Plan of Correction:	ED, RCD, and or/Designees will partner with outside agency to ensure all wound care and treatments outside of scope of practice is performed in accordance with physician's orders. Ongoing.