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 14, 2022

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:

The LI for Bentley Commons conducted a monitoring visit at the facility on 04/14/2022 from 8:45am until 1:30pm in conjunction with another LI and the LA. A tour of the facility physical plant was conducted and required posting were noted. The morning exercise activity and mid day meal were observed. The morning medication pass was observed and medication carts were audited. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. An exit interview was conducted with the facility Administrator and Director of Nursing on the day of inspection in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-560-F
Description:	Based on observation during medication pass, the facility failed to ensure all records were treated confidentially and that information is made available only when needed for care of the residents. EVIDENCE: 1. The LI noted that the small trash container located on the side of the third floor medication cart contained an empty blister pack for resident 9 for Potassium CL ER. The trash can did not have a lid and content inside the trash can were visible to anyone. The resident information had not been marked out by staff prior to being placed in the trash container.
Plan of Correction:	ED and DON had a staff meeting and in-service on how to ensure resident records are treated confidentially and how resident information is made available only when needed for the care of the resident. Additionally, ED and DON discussed with the RMA?s how to properly dispose of medication cards that have resident information located on them. 4/22/22
Standard #:	22VAC40-73-660-B
Description:	Based on observations made of the facility?s physical plant and resident record review, the facility failed to ensure that medications kept in residents? rooms were stored in an out of sight place in the residents? rooms and for only residents who have been assessed as capable of self-administering their own medications. EVIDENCE: 1. At approximately 9:30AM, the LI observed an Albuterol HFA inhaler on the table beside the bed in resident 5?s bedroom. The uniform assessment instrument (UAI) for resident 5, dated 03/07/2022, has documentation that the resident requires medications to be administered by facility staff. There was not a physician?s order for this medication in the record for resident 5. 2. At approximately 10:01AM, the LI observed the following on the table beside the bed in resident 6?s bedroom: Systane eye drops, a bag of Honey Lemon Cough Drops, Saline Nasal spray, Vaporizing Rub, and Cortizone-10. The UAI for resident 6, dated 03/10/2022, has documentation that the resident requires medications to be administered by facility staff. There were not physician?s orders for these medications in the record for resident 6.
Plan of Correction:	facility policy on medication administration as it pertains to self-administering of medications and storage of medications in their rooms. 4/22/22. ED will send out a letter to residents and POA?s reminding them of the facility policy on medication administration as it pertains to self-administering of medications and storage of medications in their rooms. 4/29/22. DON or designee will check rooms weekly for compliance regarding the storage of medications and the self-administering of medications. 5/30/22
Standard #:	22VAC40-73-680-D
Description:	Based on observation during medication pass, the facility failed to ensure that a registered medication aide (RMA) administered medications consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: During the morning medication pass observation conducted on 04/14/2022, the LI observed staff person 2 passing medications at approximately 9:22AM on the third floor of the facility. Staff person 2 was not wearing identification as required by the Board of Nursing Regulations Governing Medication Aides, which is covered in Chapter 1, Objective 1.3 of the current RMA curriculum approved by the Virginia Board of Nursing. Staff person 2 confirmed with the LI that she was not wearing her name tag.
Plan of Correction:	ED and DON counseled staff person two regarding her not wearing her name tag, per the Virginia Board of Nursing regulations. 4/19/22 ED and DON in serviced staff regarding always wearing name tags while in the facility. 4/22/22
Standard #:	22VAC40-73-680-E
Description:	Based on observation, resident interview and resident record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. The record for resident 4 contained a physician?s order, dated 04/11/2022, for Knee High Ted Hose apply in the morning and remove in the evening for edema to both legs. 2. The individualized service plan (ISP) for resident 4, dated 03/17/2022, indicates that the resident will receive physical assistance to include application and removal of Ted Hose daily and as needed to promote healthy circulation and prevent edema in the legs and this service is to be provided by LPNs and RMAs at the facility. 3. The LI observed staff person 2 administer resident 4?s scheduled 9AM oral medications; however, the LI did not observe staff person 2 apply resident 4?s Ted Hose. The LI interviewed resident 4 and the resident indicated that he did not have his Ted Hose on. The LI observed that the resident had on long, black socks and his Ted Hose were located on the chair in his bedroom. Staff person 2 documented on the medication administration record (MAR) on this date with her initials that the resident did have on his Ted Hose. 4. The licensing administrator, two licensing inspectors and staff person 3 observed resident 4 later during the inspection in his room and staff person 3 agreed that the resident did not have on Ted Hose and that he was wearing black socks. Staff person 3 proceeded with putting on the resident?s Ted Hose.
Plan of Correction:	ED and DON counseled staff person two regarding the proper use of ted hose and how to differentiate between ted hose and socks. 4/22/22
Standard #:	22VAC40-73-680-H
Description:	Based on a review of resident medication administration records (MARs) and interviews with staff and resident, the facility failed to ensure that only medications that were administered to residents were documented on on resident MARs. EVIDENCE: 1. The LI observed staff person 1 administering medications at 9:23am on 04/14/2022. When staff person 1 opened the April 2022 MAR for resident 2 it was noted that staff person 2's initials were present for administering the following morning medications; Lisinopril 10mg, MVI, Senna 8.6mg, Pantoprazole 40mg, Ensure Liquid, Polyethylene Glycol 17 grams in water. Several of these medications were noted to still be in the bubble pack on the medication cart for the 04/14/2022 dose. Staff person 1 and the LI interviewed resident 2 who expressed that no morning medications had been brought in or administered to her as of the time of the interview. An interview was conducted with staff person 2 in the presence of staff persons 3 and 4 on the day of inspection. Staff person 2 expressed that she had signed off the morning medications for resident 2 but had not administered them. Staff person 1 was made aware of this and all morning medications were then administered to resident 2.
Plan of Correction:	ED and DON counseled staff person two regarding proper documentation of medications being administered. 4/19/22. Staff person two will be going through a medication refresher course on 4/28/22 . DON and ED in-serviced RMA?s regarding proper documentation of medications being administered. 4/22/22