1 Inspection Summary
Inspection Reports Summary
Covers 44 inspections · Jan 2021 – Dec 2025Visit Reason
This report covers all inspections and complaint surveys conducted at Bentley Commons at Lynchburg by the Virginia Department of Social Services between January 25, 2021 and December 4, 2025.
Complaint Details
There were 18 complaint visits during the inspection history. Complaints involved areas such as staffing and supervision, resident care and related services, admission, retention and discharge of residents, emergency preparedness, and administration. Investigations supported some but not all allegations, and violations were issued accordingly.
Findings
Across that history VDSS cited 135 violations under 64 distinct standards across 44 inspections, including 18 complaint visits.
Violations (137)
22VAC40-73-640-A: Failed to follow medication management plan for controlled narcotics destruction.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: Medication Administration Record (MAR) missing dosage information.
22VAC40-73-680-A: Staff failed to administer drugs to residents dependent on medication administration as documented.
22VAC40-73-660-B: Resident medication not stored out of sight or accessible to others as required.
22VAC40-73-280-B: Failed to maintain written staffing plan matching actual direct care staff.
22VAC40-73-450-F: Individualized service plans not reviewed and updated annually or as needed.
22VAC40-73-680-I: MAR missing dosage information for insulin sliding scale.
22VAC40-73-680-A: Failed to ensure medications administered by licensed or provisional staff as required.
22VAC40-73-660-B: Resident medication stored improperly in resident's room.
22VAC40-73-1070-B: Harmful materials accessible to residents with serious cognitive impairments.
22VAC40-73-650-A: Medications started, changed, or discontinued without valid physician orders.
22VAC40-73-650-A: Medications started, changed, or discontinued without valid physician orders.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-450-E: ISP not signed and dated by resident or legal representative.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented per physician orders.
22VAC40-73-660-B: Resident medication stored improperly in resident's room.
22VAC40-73-1070-B: Harmful materials accessible to residents with serious cognitive impairments.
22VAC40-73-550-G: Failed to review resident rights and responsibilities annually with residents and staff.
22VAC40-90-40-B: Criminal history record report not obtained on or prior to 30th day of employment.
22VAC40-73-100-C-1: Failed to follow infection control program regarding PPE use during medication pass.
22VAC40-73-410-A: Failed to provide orientation and obtain signed acknowledgment upon admission.
22VAC40-73-450-H: Care and services specified in ISP not provided to residents.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing dosage information for insulin sliding scale.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
22VAC40-73-680-D: Medications not administered per physician or prescriber instructions.
22VAC40-73-680-I: MAR missing date/time and initials of staff administering medication.
Report Facts
Violations cited: 135
Distinct standards: 64
Inspections on page: 44
Inspections with violations: 31
Complaint visits: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
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