VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brighter Living Assisted Living and Memory Care
5301 Plaza Drive
Hopewell, VA 23860
(804) 458-5830

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Sept. 20, 2019

Complaint Related: No

Comments:

A Representative with the Division of Licensing conducted an unannounced, non-mandated, monitoring inspection on 09/20/2019 from approximately 10:30am to 1:55pm. The monitoring inspection was a result of a facility reported incident. The Licensing representative reviewed a resident record, observed the facility physical plant and interviewed resident and staff. During the inspection the Licensing Representative found identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring preventative measures. Please contact the Licensing Inspector, Kimberly Rodriguez at 804-395-5696 or by email at Kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-650-C
Description:	Based on record review the facility failed to ensure Physicians or other prescribers order is reviewed and signed by a physician or other prescriber within 14 days. Evidence: While reviewing resident record #1, documentation showed a verbal order was requested by the facility staff on 07/20/2019 which read, ? Half Rails on bed for safety to prevent resident from falling out of bed. 30 days.? On 09/20/2019 when the Licensing Inspector arrived to the facility the facility was not able to provide a signed order provided by the physician, however based on observation of resident #1?s bed and charting notes, resident #1's bed contained rails.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-710-B
Description:	Based on resident and staff interviews and observation, the facility failed to ensure physical restraints where only used for medical /orthopedic restraint support, according to a physician written order with the consent of the resident or his legal representative. Evidence #1: While interviewing resident #1 concerning the lap buddy that was currently applied, resident #1 was only able to demonstrate how to remove and purpose of the lap buddy with consistent verbal prompting and queuing provided by staff #1. Evidence #2: Resident #1?s Individualized Service Plan updated on 07/19/2019 read , ?Resident needs slot rails in bed to prevent from falling?. Resident #1's Individualized Service Plan did not identify the use for the slot rails on the bed as for medical/orthopedic support. Evidence #3: Charting notes dated 08/07/2019, " she ate 75% of dinner she set in living room and fuss about her lap buddy she wants it off". Evidence #4: While reviewing the Individualized Service Plan for resident #1, documentation showed that resident #1?s Individualized Service Plan was reviewed with resident #1?s responsible party on 07/08/2019. The Individualized Service Plan was updated on 07/12/2019, to identify ?resident needs lap buddy to prevent falling?. The facility did not provide to the Licensing Inspector written consent of the residents legal representative being notified of the restraint use. Evidence #5 Charting notes from facility dated 08/30/2019 read "Resident had to be repositioned in bed X3 during this shift. Due to resident sliding down in bed, feet and arms hanging off the bed" Evidence #6: Charting notes dated 08/30/2019 read, " Resident is sliding down in wheelchair frequently, resident complaining of pain on her buttocks. Evidence #7: Charting notes read, " resident had to be redirected several times to not take her safety strap off. "
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-710-C
Description:	Based on resident record reviews, the facility failed to ensure if a restraint is used, it must be imposed in accordance with a physicians written order that specifies the condition , circumstances, and duration under which the restraint is to be used. Evidence: While reviewing the record for resident #1, documentation showed resident #1 had an order provided by the physician dated 07/12/2019 which read, ? Lapbuddy to be engaged anytime pt is seated in wheelchair?. The order did not provide specified condition or circumstances in which the restraint was to be used.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-710-D
Description:	Based on resident record review and staff interviews, the facility failed to ensure, whenever physical restraints are used direct care staff keep a record of restraint usage, outcomes, checks and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrence or problem. Evidence: While reviewing facility charting notes for resident #1, facility staff was not able to provide documentation of record keeping regarding outcomes and 30 min checks. Staff #1 confirmed that the facility had just began record keeping and did not have records for the 30 minute checks for resident #1.
Plan of Correction:	Not available online. Contact Inspector for more information.