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: Aug. 21, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/21/2024 10:50 to 12:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 8/13/2024 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: 63 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 276-623-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, staff record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included the date and time given and initials of direct care staff administering the medication. EVIDENCE: 1.The licensing inspector received a self-report of noncompliance on 08/13/2024 from the facility which contained documentation that resident 1 was not administered their medication Clonazepam 0.5mg on 8/9/24 and 8/11/24. The medication was signed off on in the Electronic Medication Administration System (EMAR) by staff 2 but was not signed off on in the Narcotic book by staff 2, however, Narcotic count was correct. Staff 2 was interviewed by facility staff, and staff 2 stated that they did not give it and that they had signed off in error on the EMAR. 2.Resident 1 record contained an August 2024 MAR with documentation for the scheduled 9pm Clonazepam .5mg Tablet being administered on 8/9 and 8/11 by staff 2. 3. Staff 2 record contained an Employee Counseling Record dated 8/12/2024 with documentation that staff 2 signed off on 8/9 and 8/11 that they had administered resident 1 scheduled 9pm Clonazepam .5mg Tablet, and the medication was found in the back of the narcotic drawer by staff 4. 4. On the day of inspection during interviews with one licensing inspector and staff 1 and then staff 5, staff 1 and then staff 4 confirmed the resident did not receive their scheduled 9pm Clonazepam .5mg Tablet. Staff 1 and Staff 4 confirmed the medication was on the cart, however, staff 2 did not administer it to the resident according to the narcotic log sheet and staff 2 interview.
Plan of Correction:	A mandatory in-service was held for RMAs to review the correct procedures for administering and documenting medications. RMA involved was required to complete a medication refresher course. Following this, the Healthcare Director or designee conducted individual medication pass reviews with the RMA.