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: Feb. 11, 2022 and March 1, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Sworn Statement or Affirmation

Comments:

An unannounced renewal inspection was conducted at the facility on February 11, 2022 from 8:49 am to 12:30 pm with an exit call conducted by phone March 1, 2022 to conclude the inspection. There were 44 residents in care on the date of inspection. A tour of the facility was conducted onsite to include a medication observation, meal observation, and activity observation. The following records were reviewed: Resident and staff records, menus, activities calendars, buildings and grounds, resident council, fire and emergency drills, pharmacy and healthcare oversight. Thank you for your cooperation during this inspection. I can be reached at alex.poulter@dss.virginia.gov or (804) 662-9771.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview with staff, the facility failed to ensure that the physical examination required within the 30 days preceding admission contained the date of the physical examination and the description of the person's reactions to any known allergies. Evidence: 1. Resident #2 admitted 2-01-2021. Resident #2?s?s ?Report of Resident Physical Examination? did not contain the date of examination, nor the allergy reactions to ?PCN? and ?codeine? that were listed on the examination. 2. Resident #3 admitted 9-30-2021. Resident #3`s ?Report of Resident Physical Examination? did not contain the date of examination. 3. Resident #5 admitted 1-04-2022. Resident #5?s ?Report of Resident Physical Examination? did not contain the date of examination. 4. Resident #7 admitted 2-01-2021. Resident #7?s ?Report of Resident Physical Examination? did not contain the resident?s allergy reaction to ?codeine? that was documented on the examination.
Plan of Correction:	Sale Director will ensure all new admissions will have the date of the physical examination and description of reactions to any known allergies prior to admission. Administrator will check all paperwork prior to admission to ensure this has been completed.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall. Evidence: 1. Resident #5?s record contained ?Physician Notification of Resident Condition (Fall)? for falls on the following dates: 1-04-2022, 1-10-2022, 1-11-2022, 1-17-2022, and 1-18-2022. 2. There were no fall risk ratings for Resident #5?s aforementioned falls.
Plan of Correction:	DON/RCC will ensure all fall risk ratings are completed/updated after each fall. Administrator will full up each monthly to ensure they have been completed. Incident/fall reports will be kept in binder according to month as well as a copy of fall risk rating.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview with staff, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed whenever there is a significant change in the resident's condition. Evidence: 1. Resident #6 admitted 11-11-2019 to the community, and 12-21-2021 to the safe, secure environment (SSE). Resident #6?s ISP dated 11-09-2021 documented wandering behaviors; however, Resident #6?s UAI dated 11-08-2021 did not document wandering behaviors. 2. Resident #8 admitted 2-19-2021 to the SSE. Resident #8?s UAI dated 8-19-2021 did not document aggressive behaviors; however, three incident reports were received regarding Resident #8 striking other residents on 11-13-2021, 12-04-2021, and 2-18-2022. 3. Staff #1 confirmed the UAIs were not updated to reflect Resident #6 or Resident #8?s behaviors.
Plan of Correction:	DON/RCC will ensure all UAIs stay current and up to date. Administrator and DON/RCC will meet bi-weekly to discuss resident changes and address UAIs as needed.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) documented the date of identified needs based upon the Uniform Assessment Instrument (UAI) and admission physical exam. Evidence: 1. Resident #2 admitted 2-01-2021 to the facility. Resident #2?s ISP dated 1-26-2021 did not contain a date identified for any of the services listed. Additionally, Resident #2?s ISP did not contain the resident?s allergies or allergy reactions that were identified on the ?Report of Resident Physical Examination? documenting allergies to Penicillin and Codeine. 2. Resident #5 admitted 1-04-2022 to the facility. Resident #5?s ISP dated 12-21-2021 did not contain a date identified for any of the services listed. Additionally, Resident #5?s ISP did not contain the resident?s allergy or allergy reactions identified on the ?Report of Resident Physical Examination? documenting allergies to Amoxicillin and Lisinopril. Resident #5?s UAI dated 12-08-2021 documented hearing issues, using a rollator walker, and disorientation that was not on the resident?s ISP. 3. Resident #7 admitted 2-01-2021. Resident #7?s ISP dated 2-01-2021 did not contain a date identified for any of the services listed. Resident #7?s ISP did not contain the resident?s allergy or allergy reactions identified on the ?Report of Resident Physical Examination? documenting an allergy to Codeine. 4. Staff #1 confirmed Resident #2, Resident #5, and Resident #7?s most current ISPs did not contain the date of identified needs for any needs listed and that allergies and allergy reactions were not listed for the aforementioned residents on their ISPs.
Plan of Correction:	RCC/DON/designee will ensure all dated of identified needs are documented on ISP. Administrator will review monthly to ensure it is completed.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to provide attention to specialized needs, such as wandering from the premises. Evidence: 1. Resident #6 admitted 11-11-2019 to the facility. Resident #6?s ?Physician Progress Note? dated 6-28-2021 documented, ?Interval History: Staff c/o (complains of) ' (increased) confused, wandering was ?lost outside??? and ?Plan: ?.monitor closely needs chaperone to go outside?. 2. A self-reported incident received by the licensing office via email on 12-21-2021 documented that on 12-18-2021 at approximately 6:45 a.m., ?Resident [#6] left facility with [Resident #6] coat on but did not sign out. [Resident #6] was found at the Moose Lodge. [Resident #6] was returned approx. 1 hour later by Hopewell police? Resident does have a diagnosis of dementia.? 3. A subsequent ?Physician Progress Note? dated 12-20-2021 documented, ?Interval History: Wandered out of facility ' confusion??. 4. Resident #6?s ISP dated 11-09-2021 documented, ?Resident needs to be checked on in their rooms to attempt to maintain safety and well-being due to wandering and insomnia.? 5. Staff #1 confirmed during interview that Resident #6 exhibited wandering behaviors and wandered from the premises on 12-18-2021.
Plan of Correction:	DON/RCC/Administrator will address all specialized needs when they arise and update ISP accordingly.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to implement a written plan for medication management including methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs). Evidence: 1. Resident #1?s physician?s order dated 5-24-2021 for ?Latanoprost 0.005% ophthalmic solution, 1 drops, Eye-Both, bedtime? was documented on the February 2022 MAR as to be administered at 9:00 a.m. instead of bedtime as ordered. 2. The facility?s ?Medication Administration Plan? revised August 2011 documented, ?5. Transcribing Medication Orders. a. The medication order should be transcribed exactly as it is written on the physician?s order.? 3. Resident #1 was administered Latanoprost 0.005% ophthalmic solution at approximately 9:35 a.m. on 2-11-2022 during the medication administration observation. 4. Staff #1 acknowledged during interview that the facility staff did not accurately transcribe the medication order to the MAR and stated that, ?A nurse had reportedly changed the order due to Resident #1 stating she was not receiving the medication at bedtime? and acknowledged there was not a new order documented.
Plan of Correction:	DON/RCC will do weekly order to MAR audits to ensure orders match the MAR. Med techs will completed New Med Order Checklist (See attachment 1), once completed forms will be placed in box for RCC/DON to review, once reviewed forms will be kept in binder for three months.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, observation, and interview with staff, the facility failed to ensure medications were administered in accordance with the physician?s instructions. Evidence: 1. Resident #1?s physician?s orders dated 5-24-2021 documented, ?Latanoprost 0.005% ophthalmic solution, 1 drops, Eye-Both, bedtime?. 2. Staff #12 administered Latanoprost 0.005% ophthalmic solution on 2-11-2022 at approximately 9:35 a.m. from the medication cart ?West Cart? during inspection. 3. Resident #1?s February 2022 Medication Administration Record (MAR) documented for 2-11-2022 at 9:00 a.m. the initials ?AP? for ?Agency People? per the ?Caregiver Key?. 4. Staff #1 acknowledged the physician?s orders instructed for Resident #1?s medication to be administered at bedtime and that the medication was administered in the morning.
Plan of Correction:	All staff administering medications will receive in-service from pharmacy on proper way to administer medications.
Standard #:	22VAC40-90-30-C
Description:	Based on record review and interview with staff, any person making a materially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor. Evidence: 1. The following staff checked ?no? on the question ?Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?? on the sworn statement or affirmation; however, the staff had been convicted that was documented on the Criminal Record Reports (CRR): a. Staff #2: date of hire (DOH) 10-24-2021 (CRR dated 8-12-2021); b. Staff #3: DOH 1-02-2020 (CRR dated 12-19-2019); c. Staff #6: DOH 12-07-2021 (CRR dated 9-30-2021); d. Staff #7: DOH 10-05-2021 (CRR dated 9-21-2021); e. Staff #8: DOH 11-30-2021 (CRR dated 11-10-2021); f. Staff #9: DOH 9-21-2021 (CRR dated 9-14-2021); g. Staff #10: DOH 8-17-2021 (CRR dated 8-10-2021); and h. Staff #11: DOH 1-25-2022 (CRR dated 1-12-2022). 2. Staff #1 confirmed the aforementioned staff made materially false statements on the sworn statement/affirmation regarding convicted law violations.
Plan of Correction:	All sworn statements will reflect CRR. Moving forward BOM will ensure all sworn statements reflect CRR. Administrator will audit all new hires monthly to ensure sworn statements are correct.