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: June 14, 2021

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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 6/14/2021 and concluded on 6/16/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 52. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, health care oversight, medication management plan and infection control, fire and health inspections, fire drill logs, and dietician oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on a review of staff records, the facility to ensure that training in working with individuals who have cognitive impairments was completed within four months of the start date of employment for all direct care staff. EVIDENCE: 1. The record for staff person 1, hired on 10/19/2020, does not contain any documentation that the employee has received any training for individuals with cognitive impairments.
Plan of Correction:	Staff training records will be audited and all staff that have not received the cognitive impairment training requirements will be given any and all necessary cognitive impairment training as required to be within compliance. Training will continue to be ongoing.
Standard #:	22VAC40-73-120-A
Description:	Based on a review of staff records, the facility failed to ensure that required orientation and training occurred within the first seven working days of employment. EVIDENCE: 1. The record for staff person 1, hired on 10/19/2020, has documentation that the required orientation and training was not completed until 11/30/2020. 2. The record for staff person 4, hired on 3/3/2021 has documentation that the required orientation and training was not completed until 5/21/2021.
Plan of Correction:	Staff training records will be audited and all staff that have not received the orientation and training requirements will be given all necessary orientation training as required to be within compliance. All new employees will be provided the new orientation training within 7 days of employment
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that all staff received a screening for tuberculosis on or within seven days prior to the first day of work at the facility. EVIDENCE: 1. The record for staff person 3, hired on 4/18/2019, has documentation that a screening for tuberculosis was not completed until 10/16/2019. 2. The record for staff person 4, hired on 3/3/2021 does not have documentation that a screening for tuberculosis has been completed for this employee.
Plan of Correction:	Staff records will be audited and TB screenings will be conducted for current staff. Going forward, TB screenings will be conducted on or within 7 days prior to first day of work.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff person 4, hired on 3/3/2021, does not have documentation that this employee has received certification in first aid.
Plan of Correction:	Staff records will be audited and CPR/First Aid Training will be conducted for current staff. Going forward, CPR/First Aid Training will be conducted within 60 days of employment.
Standard #:	22VAC40-73-270-1
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The records for staff persons 1, 2, 3 and 4 does not have documentation that they have received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states. The facility currently serves a mixed population of residents, of which some resident have a diagnosis of dementia/cognitive impairments. An interview with staff person 5 expressed that the facility does house a residents with agitation/aggressive behaviors.
Plan of Correction:	Staff training records will be audited and all staff that have not received the aggressive training requirements will be given any and all necessary aggressive behavior training as required to be within compliance. Training will continue to be ongoing.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has documentation in resident notes dated 5/28/2021 of the resident receiving a chopped meats diet. A fall risk tool completed 9/12/2020 has that resident 1 is a risk for falls. These identified needs are not addressed on the ISP dated 9/12/2020. Also the record for resident 1 has a physician order dated 5/28/2021 for meds to be placed whole in applesauce, pudding or yogurt. The uniform assessment instrument (UAI) dated 5/19/2021 for resident 1 has documentation that the resident requires supervision with walking and physical assistance with wheeling. The ISP dated 9/12/2020 is inconsistent as it has that resident 1's medications are to be crushed and that the resident requires mechanical assistance only with walking and wheeling. 2. The record for resident 2 has documentation in resident notes of the resident refusing showers and medications. The UAI dated 5/11/2021 also has documentation of medication and shower refusals as well as that resident 2 requires physical assistance with dressing and physical and mechanical assistance with walking. The ISP dated 5/11/2021 in the record for resident 2 does not address these identified needs. 3. The record for resident 3 has documentation on a fall risk tool dated 3/19/2021 that the resident is a fall risk. The ISP dated 6/5/2021 in the record for resident 3 does not address this identified need. 4. The record for resident 4 has a physician order dated 6/1/2021 for an Aspen collar to be worn PRN (as needed). The ISP dated 3/30/2021 in the record for residnet 4 is inconsistent as it has documetatio that the collar is to be worn daily.
Plan of Correction:	1.Director of Nursing will conduct chart audits, UAI and ISP audits and make corrections to UAI and ISPs of all current residents. Director of Nursing and Executive Director will ensure that all needed services are identified and UAI and ISPs match for both current and new residents. 2. Any services that residents refuse will be documented on the ISPs. Staff will be trained and informed to document refusals. Resident?s physicians will be notified of any services that are refused. 3. During chart audits, any resident who has been identified as a fall risk, will have risk documented on ISP. Fall risks will be updated annually and as needed and reflected on the ISP. 4. During audit of UAIs and ISPs, treatment orders will be identified and corrected and documented correctly on ISPs. Going forward, any changes in treatment orders will be reflected on ISP
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records, the facility failed to ensure that a review of resident rights and responsibilities was conducted annually with all staff. EVIDENCE: 1. The record for staff person 2 hired on 5/3/2016 does not contain documentation of an annual review of resident rights. 2. The record for staff person 3 hired on 4/18/2019 does not contain documentation of an annual review of resident rights.
Plan of Correction:	Staff records will be audited and resident rights will be reviewed for current staff. Going forward, all new hires will receive resident rights review upon employment and all staff will review annually
Standard #:	22VAC40-73-640-A
Description:	Based on a review of the facility medication managment plan, the facility failed to ensure all required procedures were addressed in the plan. EVIDENCE: 1. The facility medication management plan that was submitted for review does not address all required procedures per this standards requirement.
Plan of Correction:	Executive Director will review current Medication Management Plan and re-write plan to include all required procedures per standards requirements to be within compliance.
Standard #:	22VAC40-73-650-F
Description:	Based on a review of resident records, the facility failed to ensure that that a residents primary care physician was made aware of all new/changes in medication orders when a resident returned to the facility from a hospital admission. EVIDENCE: 1. The record for resident 3 has documentation of an orders reconciliation report from a local hospital signed by the hospital physician on 6/7/2021 when resident 3 was discharged and returned to the facility. There are discrepancies noted between the medications listed on the Orders reconciliation report and the residents current June 2021 MARs from which medications are being administered. The record for resident 3 does not have documentation that resident 3's primary care physician was notified and made aware of the discrepancies or of any further physicians order since the 6/7/2021 reconciliation report.
Plan of Correction:	Nurses or Director of Nursing will notify residents? Primary Care Physicians of any changes in orders immediately. PCP outside of facility will be notified immediately on physician order sheet by fax and phone. House physician will be called immediately for notification and will review/sign physician order sheets during next clinical visit.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to administer medications i accordance with physician instructions. EVIDENCE: 1. The record for resident 3 has a physician order dated 6/7/2021 for Ferrous Sulfate (Ferosul 325mg (65mg elemental iron) 1 tablet every other day. The June 2021 MAR for resident 3 has Ferrous Gluconate 324mg , 1 tablet every 2 days listed and this was the medication noted to be on the medication cart for administration. 2. The May 2021 MAR for resident 4 has a physician order dated 2/26/2021 for Furosemide 20mg daily as needed for CHF if weight goes up 2 pounds from 120.2. The MAR has documentation of the residents weight being above the 2 pound weight parameter and requiring the administration of the Furosemide on 5/1/2021, 5/8/2021, 5/9/2021 and 5/12/2021 but there is no documentation that it was administered on these days. Also there are staff initials documentation for the administration of this medication twice on 5/5/2021 but the physician order is for daily admiistration.
Plan of Correction:	1. Nurses or Director of Nursing will notify residents? Primary Care Physicians of any changes in orders immediately. PCP outside of facility will be notified immediately on physician order sheet by fax and phone. House physician will be called immediately for notification and will review/sign physician order sheets during next clinical visit. 2. Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.
Standard #:	22VAC40-73-680-E
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that all medical procedures were documented as required. EVIDENCE: 1. The May 2021 MAR for resident 1 has a physician order for daily weights to be recorded. The MAR does not have staff initials or the record weight on 5/16/2021 or 5/24/2021. 2. The May 2021 MAR for resident 2 has a physician order for wound treatment to the residents left thigh on Mondays, Wednesdays and Fridays to be completed by Hospice nurse. The MAR does not have any initials for the completion of this treatment on 5/3/2021, 5/5/2021, 5/7/201, 5/10/2021, 5/12/2021 or 5/14/2021. 3. The May 2021 MAR for resident 3 has a physician order for daily weight checks for monitoring and PRN medication if needed. The MAR does not have documentation of the residents weight on 5/20/2021.
Plan of Correction:	1.Director of Nursing and/or LPNs will be conducting daily MAR checks. 2. Medication Aides and Nurses will sign off that Home Health or Hospice Nurses have completed treatments and document on MAR. Executive Director and/or Director of Nursing will notify Home Health and Hospice Agencies that their nurses will be required to document in resident?s charts that treatments have been conducted and completed.
Standard #:	22VAC40-73-680-I
Description:	Based o a review of resident medication administration records (MARs), the facility failed to ensure that all required documentation was included on resident MARs. EVIDENCE: 1. The May and June 2021 MAR for resident 1 does not have staff initials for the administration of the prescribed medications Acetaminophen 325mg 2 tablets at 9 pm on 5/21/2021, Diclofenac Sodium 1% at 9pm on 5/7/2021 and 5/8/2021, Guaifenesin ER 600mg at 9pm on 5/21/2021, Latanoprost 0.005% eye drops at 9pm on 5/21/2021,Metoprolol 50mg at 6am on 5/9/2021, 5/10/2021, 5/14/2021, 5/19/2021, 5/24/2021, at 2pm on 5/26/2021, and at 10pm on 5/11/2021, 5/21/2021, 5/30/2021, 6/3/2021 and 6/4/2021, Zinc Sulfate 220mg at 6pm on 5/7/2021, 5/8/2021 and 5/21/2021. 2. The May and June 2021 MAR for resident 2 does not have staff initials for the administration of the prescribed medications Levothyroxine 112mcg at 6am on 5/8/2021 through 5/10/2021, 5/14/2021, 5/19/2021, 5/25/2021 and 6/2/2021, Voltaren 1% gel at 9pm on 5/7/2021, 5/8/2021 and 5/21/2021, Docusate Sodium 100mg at 9pm on 5/21/2021. 3. The May 2021 MAR for resident 3 does not have staff initials for the administration of the prescribed medications Levothyroxine 88mcg at 6am on 5/9/2021 and 5/10/2021. 4. The May and June 2021 MAR for resident 4 does not have staff initials for the administration of the prescribed medications Buspirone 5mg at 2pm on 5/17/2021 and 5/22/2021, Levothyroxine 75mcg at 6am on 5/6/2021, 5/9/2021, 5/10/2021 and 6/6/2021.
Plan of Correction:	Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.
Standard #:	22VAC40-73-970-A
Description:	Based on a review of facility documentation, the facility failed to conduct fire drills on each shift quarterly. EVIDENCE: 1. The facility fire drill log does not have documentation of a fire drill being conducted from February 2020 through April 2021.
Plan of Correction:	Fire drill reviews with staff restarted in April 2021 and conducted monthly. Going forward, fire drill reviews will continue to be conducted and documented monthly.
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 applicants of employment. EVIDENCE: 1. The records for staff persons 4, 15, 16, 17, 18, 19, 20, 21 and 22, all of whom are current employees at the facility, does not contain documentation that a sworn statement or affirmation was completed prior to their employment.
Plan of Correction:	Executive Director and/or Business Office Manager will audit employee charts and have current employees sign a sworn statement to keep within records. Going forward, all new employees will sign a sworn statement prior to or no later than first day of work.
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to ensure that a criminal history report was obtain on new staff on or prior to their 30th day of employment. EVIDENCE: 1. The records for staff persons 1, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20 and 21, all of whom have been employed at the facility for longer than 30 days, does not contain documentation that the facility has obtained a criminal history record report for these employees.
Plan of Correction:	Executive Director and/or Business Office Manager will audit employee charts and have criminal history reports obtained for all current employees lacking this document to keep within records. Going forward, all new employees will have a criminal history report conducted prior to and/or no later than 30 days after first day of work.