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: Oct. 25, 2019 and Nov. 5, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS

Comments:

Two Representatives with the Division of Licensing jointly conducted an unannounced, non-mandated, inspection on 10/25/2019 from 10:25am to 5:44pm and completed the inspection on 11/05/2019 from 8:40am to 11:54am. The inspection was a result from a facility reported incident. During the inspection the Licensing Inspectors observed areas of non-compliance which are detailed.Please complete the "plan or correction" and "date to be corrected" for each violation cited on the violation notice and return 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. Please contact the facility Licensing Inspector Kimberly Rodriguez at 804-396-5696 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on record review and emergency room discharge summary the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence #1: On 10/25/2019, documentation provided in resident #1's record evidenced that resident #1 sustained a fall on 10/04/2019 and was sent out to the emergency room. The discharge summary dated 10/04/2019 documented under "Your Home Care Instructions/Diagnoses" " Head Injury, Staple Wound Closure, Wound Care- Scalp Laceration. Evidence #2: On 10/25/2019 documentation provided on the facility charting note dated 10/04/2019 reads, " RP, was notified at approx. 2pm that (resident #1) got up from (resident #1's) wheelchair and proceeded to fall backwards onto (resident #1's) back before staff could get to (resident #1) in time to prevent( resident #1) from falling. (resident #1) sustained a laceration to the back of head and after reviewing the camera footage it looks like (resident #1's) head "bounced" forward hitting the hinge on the closet door and causing a cut to the top of (resident #1's) forehead. (resident #1) was transported via ambulance". Evidence #3: When Licensing Representatives arrived on 10/25/2019 the facility had not reported within 24 hours the major incident that negatively affected the residents life or health. Based on interview with staff #1, staff #1 had faxed the notification. The facility Licensing Inspector allowed staff #1 the opportunity to locate documentation, however staff #1 declined to look for any supporting documentation to validate the information had been reported to the regional licensing office.
Plan of Correction:	Administrator will ensure that incident's will be reported to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. We now have a new fax machine and have programmed our fax machine to print out a confirmation of report and have instructed our administrative assistant to attached the confirmation of report to the incident report. Administrator will email incident reports to the Regional licensing office when appropriate. Adult Protection will also be notified within 24 hours of any major incident.
Standard #:	22VAC40-73-150-C
Description:	Based on staff interviews, emergency room discharge summaries and record review the facility administrator failed to be responsible for the general administration and management of the facility by failing to ensure care is provided to residents in a manner that protects their health,safety and well-being. Evidence #1: While conducting interviews on 10/25/2019 with staff #1 and #2, the facility Licensing Inspector inquired to staff #1 regarding any changes to protect resident #1's health and well-being since resident #1 had sustained injury on 10/23/2019 resulting in facial fracture. Staff #1 confirmed no changes were made to protect the resident health nor well-being. Evidence#2: On 10/25/2019 and 11/05/2019, documentation provided, evidenced resident #1 sustained fall and/or injury dated, 06/12/2019, 06/26/2019( resulting in scalp laceration with 12 staples), 06/28/2019, 06/29/2019, 07/14/2019 (resulting in abrasion and scalp sutures(dis-solvable) 09/13/2019, 09/30/2019, 10/04/2019 and 10/23/2019(resulting in fracture). Evidence #3: On 11/05/2019 during an interview with staff #1, the Licensing Inspector inquired to staff #1 as to the protocol for determining if the facility can meet the residents needs. Staff #1 stated, "when a resident has issues with gait, transfers, resident is having continuous falls and when Physical and Occupational therapy is no longer an option". Staff 1 also informed that resident #1 did infact have ongoing issues with transfers, gait, continuous falls and informed that the Physician informed the facility that Physical and Occupational therapy had not been feesable for resident # 1 in the past. Staff #1 informed that resident #1 was assessed on 10/29/2019 for Physical and Occupation therapy and was informed that they could not assist as resident #1 cannot follow cues. Evidence #4: Based on interviews with staff #1 and #4, staff #1 was notified during multiple facility " stand up" meetings of resident #1's ongoing falls and/or injury.
Plan of Correction:	The Administrator will ensure care is provided to residents in a manner that protects their health, safety and well-being. The Administrator, Director of Admission and the Director of Nursing in a combined effort will ensure the development, implementation and monitoring of an individualized service plan for each resident. We will continue with morning stand up with each department to discuss any change in conditions, falls, family concerns and make additional changes in their care to their individualized care plan. Administrator, Director of Admission and Director of Nursing attended the Phase II training on 12/12/2019.
Standard #:	22VAC40-73-310-A
Description:	Based on resident record review and emergency room discharge summary the facility failed to ensure no resident was retained: for whom the facility cannot provide or secure appropriate care. Evidence: On 10/25/2019 and 11/05/2019, documentation evidences resident #1 sustained a total of nine falls/and or injuries with at least three resulting in serious injury from 06/12/2019 to 10/23/2019. When Licensing Inspectors arrived on 10/25/2019 to assess an injury which resulted in facial fracture on 10/23/2019, the facility had not put any additional measures in place to ensure resident #1's safety and was not able to meet the residents needs.
Plan of Correction:	The Administrator will ensure that no resident will be retained for whom the facility cannot provide or secure appropriate care. Resident #1 is now being provided one on one sitter 24/7 a day until secure appropriate placement into a skilled facility is obtained. A 30 day notice was given to resident's representative on 11/1/2019. Adult Protective Services was obtained and they are working on Medicaid Application. It is pending at this time. Facility has assisted resident's representative to find alternate placement and as soon as the Medicaid is approved resident will be placed appropriately in a skilled facility. There isn't a skilled facility that will accept a Medicaid Pending application. We anticipate this process to be completed within the week.