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: Nov. 22, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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 SANCTIONS.

Comments:

The LI for Bentley Commons conducted an unannounced renewal study at the facility on 11-22-19 from 8:00am until 2:30pm in conjunction with another LI and noted 75 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the facility physical plant was conducted and the morning medication pass and mid day meals was observed. Please respond with a plan of correction with 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-310-B
Description:	Based on a review of resident records, the facility failed to ensure that an interview between the administrator or designee and the resident or legal representative prior to admission was documented. EVIDENCE: 1. The records for residents 3, admitted on 11/14/19, resident 10, admitted on 9/12/19 and resident 11, admitted on 10/9/19 did not contain a documented interview in the residents records.
Plan of Correction:	A pre-admission interview sheet was created and will be completed with each UAI done prior to admission.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to update individualized service plans (ISP) when conditions of residents changed. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 4, dated 4/9/2019, shows a need for physical and mechanical help with walking. The ISP, dated 9/16/2019, shows that mechanical help only is given. Staff interview reveals the ISP is incorrect, and the resident needs both physical and mechanical help when walking. 2. The UAI for resident 12, dated 8/28/2019, shows that mechanical and human help with physical assistance is needed when the resident uses a wheelchair. The ISP, dated 8/28/2019, shows than physical assistance with human help is given, and the mechanical assistance is not addressed. 3. The record for resident 3 has a signed Do Not Resuscitate order dated 10/12/19. The ISP dated 11/12/19 in the record for this resident does not reflect this assessed need. 4. The ISP in the record for resident 5 has documentation of the use for half rails for mobility. Per staff interviews and observations in the records room, these rails are not in use.
Plan of Correction:	1. Resident will have a new UAI done and new ISP created. 2. ISP was corrected noting that resident has bright color brakes to draw attention and serve as a reminder. 3. Resident was admitted on 11/14/19 and facility received DNR then. Since DNR is durable it was dated 10-12-19 as start date. ISP is now updated. 4. ISP corrected and 1/2 side rails removed.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records, the facility failed to ensure that physician orders were maintained in resident records. EVIDENCE: 1. The individualized service plan (ISP) for resident 12 shows she uses a hospital bed and half-rail for mobility. Staff interview reveals that resident 12 has half-rails for mobility. The resident record did not have a copy of the order for the rails.
Plan of Correction:	Obtain order for hospital bed with 1/2 side rails
Standard #:	22VAC40-73-660-B
Description:	Based on observations made of the facility physical plant, the facility failed to ensure that residents who self administer medications stored their medications in an area that is inaccessible to other residents. EVIDENCE: 1. Resident 1 was noted to have Tylenol 325mg tablets, Prevagen caplets, Sinement 25/100mg tablets and Levocetrizine medications. Sitting out in the open in their room. Resident 1 does self administer these medications but they were not stored in an out of sight location that was inaccessible to other residents on the day of inspection. The LI observed that resident 1 left their room at 9:05am to go to an appointment and the door to the residents room was left unlocked. A bottle of Trazadone 50mg for resident 1's dog was also noted to be sitting out in the room.
Plan of Correction:	Self administer medication assessment was complete. Resident to be seen by MD and have all medications changed to staff administration. Resident educated again not to buy OTC medications and how to store medications in an inaccessible storage area.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, the facility failed to have prescription labels on medications. EVIDENCE: 1. Two Basaglar KwikPens (insulin glargine) were found in the medication cart in the compartment for resident 7, and neither one had a prescription label.
Plan of Correction:	Contacted pharmacy and asked for extra label for pens as pens come in a 5 pack with label and each pen has to be labeled.
Standard #:	22VAC40-73-680-C
Description:	Based on observations made of the facility morning medication pass, the facility failed to ensure that all medications were administered not later than 1 hour after the facilities standard dosing schedule. EVIDENCE: 1. The LI noted that at 9:20am residents 3, 4, 5 and 6 had not received their 8am medications. An interview with staff person 1 expressed that the morning medication pass had been delayed due to issues with the facility computer/E-MAR system.
Plan of Correction:	In-service done with all nurses stating that if computers are down for more than 5 minutes use back up MAR's.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and observations of the facility medication carts, the facility failed to ensure that medications were administered in accordance with physician orders. EVIDENCE: 1. The record for resident 1 has a physician order for Fluticasone Nasal Spray, 2 sprays to each nostril every day. A half full bottle of Fluticasone Nasal Spray was observed in the medication cart for resident 1. A facility open date of 10/18/19 was observed on the bottle and staff initials were present from 10/18/19 to current for administering this medication. The LI noted that the Fluticasone Nasal Spray was in a 120 metered dose bottle which would have only last for 30 days.
Plan of Correction:	1/2 bottle removed and new bottle opened. Staff educated, nurses to audit metered dose bottle to ensure proper use of medications.
Standard #:	22VAC40-90-30-B
Description:	Based on a review of staff records, the facility failed to ensure that a sworn statement or affirmation was completed for employment for all employees. EVIDENCE: 1. The records for staff persons 6, 7 and 8 had a sworn statement that was completed after the employees date of hire. 2. The records for staff persons 9 and 10, both hired on 2019, had sworn statements that were dated for 2017.
Plan of Correction:	DBA to ensure sworn statements are complete and dated correctly before employment commences.