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. 7, 2021 , Sept. 21, 2021 and Oct. 8, 2021

Complaint Related: Yes

Comments:

A non-mandated complaint inspection was initiated on September 7, 2021 and concluded on October 8, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, and staffing. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on September 21, 2021. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit. Evidence: 1. On the following dates, there were less than two staff in each special care unit during the day (D ? 7am ? 3 pm) and evening (E ? 3pm- 11 pm) shifts: a. July 2021: 7-03-2021: E (8p-11p), 7-11-2021: D, 7-18-2021: D, 7-19-2021: E (7p-11p); b. August 2021: 8-2-2021: D, 8-13-2021: E, 8-16-2021: E. 2. Staff #1 confirmed during interview that staffing minimums were not met in the special care unit during day and evening shifts on the aforementioned dates.
Plan of Correction:	Administrator has enlisted assistance of agency nursing to assist with staffing needs.
Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure during night hours, at least two direct care staff members were awake and on duty at all times in each special care unit with 22 or fewer residents present. Evidence: 1. On the following dates, there were less than two staff in each special care unit during the night shift (N ? 11pm ? 7 am): a. July 2021: 7-02-2021, 7-04-2021,7-08-2021, 7-13-2021, 7-20-2021 (3a ? 7a), 7-22-2021, 7-25-2021; b. August 2021: 8-01-2021 ? 8-02-2021, 8-04-2021 ? 8-05-2021, 8-07-2021 ? 08-09-2021, 8-13-2021 ? 8-15-2021, 8-19-2021 ? 8-21-2021, 8-23-2021, 8-26-2021 ? 8-29-2021. 2. Staff #1 confirmed during interview that staffing minimums were not met in the special care unit during the night hours on the aforementioned dates.
Plan of Correction:	Administrator has enlisted assistance of agency nursing to assist with staffing needs.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, 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. Resident #1 admitted on 12-28-2020 to the Safe, Secure Environment (SSE). 2. Resident #1?s Progress Notes with Physician #1 documented the resident eloped on 1-08-2021 and 3-15-2021 from the SSE of the facility. 3. The regional licensing office received no report of either incident taking place. 4. Staff #1 confirmed during interview that the incidents took place and the licensing office had no record of either incident.
Plan of Correction:	Administrator/Designee will report to DSS any/all reportable incidents within 24 hours.
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. A note from Staff #2 dated 9-27-2021 documented, ?On January 6th 2021, an incident report was completed for [Resident #1] by this writer as instructed by Resident Care Coordinator. A charting note about resident [#1] wandering away from facility was completed by this writer as well. Resident Care Coordinator notified previous Administrator about the incident. This writer is unaware of the location of the incident report after it was given to previous administrator?? (signed by Staff # 2). 2. A second note from Staff #3 dated 9-27-2021 documented, ?On March 14, 2021 an incident report was completed for [Resident #1] by this writer as instructed by Resident Care Coordinator. A charting note about this incident (resident [#1] wandering away from facility) was done also. Resident Care Coordinator notified previous Administrator about the incident. I [Staff #3] who is writing this report is unaware of what happened to the report after it was given to previous Administrator. (signed by Staff #3). 3. Resident #1?s Charting Notes from 3-14-2021 electronically signed by Staff #3 documented, ?Change in Condition: At 9:30pm resident [#1] on purple with another resident brought back to his neighborhood and to room. At 10:15pm while making rounds resident unable to be found...(MOD) ntfd, Brighter Living side ntfd. Employee and a resident from BL side spotted resident [#1] coming out of woods and saw him fall down the hill?? Progress Note by Physician #1 dated 3-15-2021 documented resident #1 received abrasions from the fall. 4. Staff #1 confirmed during interview that Resident #1 wandered from the premises on two occasions as reported by Staff #2 and Staff #3.
Plan of Correction:	Administrator/Designee ensure that rounds are made approximately every 30 minutes and all residents are accounted for on secure unit.