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: April 27, 2022

Complaint Related: No

Technical Assistance:

Consultation: Fire drill time Personal data updates

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/27/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: medication pass observation, fire and emergency drawing, meal, activity, first aid kit, resident and staff records, tour Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804)662-9971 or by email at alex.poulter@dss.virginia.gov

Violations:

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 at least annually. Evidence: 1. Resident #3 admitted 10-03-2016. Resident #3?s most current UAI on file was dated 06-28-2020. 2. Staff #1 confirmed that Resident #3?s UAI was not updated at least annually.
Plan of Correction:	DON/RCC/ Administrator will meet at the beginning of each month to ensure all ISP are up to date according to their due date or if conditions have changed. Due dates will be kept in a calendar as well as a binder with all the ISP/UAI filed for the month they need to be completed.
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) included the description of identified needs and date identified based upon the UAI; and home health services of the resident. Evidence: 1. Resident #2?s physician?s orders dated 12-20-2021 documented, ?Re: Wound care sacral ulcers Thank you?. Resident #2?s ?Home Health Certification and Plan of Care? documented services ?start of care? date 12-23-2021 and was ongoing through 04-21-2022. As of the date of inspection, home health was still involved treating two wounds, one to right heel and one to right hip per Staff #1. Resident #2?s home health services were not identified on Resident #2?s ISP dated 12-30-2021. 2. Resident #3 admitted 10-03-2016. Resident #3?s ISP dated 06-28-2020 did not document resident needing assistance with walking, wheeling, or mobility; however, Resident #3?s UAI dated 06-28-2020 documented, ?human help, physical assistance? with walking, ?mechanical help? with wheeling, and ?mechanical help, human help physical assistance? with mobility. 3. Resident #4 admitted 02-11-2022. Resident #4?s ISP dated 02-11-2022 did not document resident needing assistance with walking or mobility; however, Resident #4?s UAI dated 02-08-2022 documented, ?mechanical help? (cane) for walking and ?mechanical help? (cane) for mobility. 4. Staff #1 confirmed the home health services were not documented on Resident #2?s ISP, and that Resident #3 and Resident #4?s ISPs did not contain services identified from the UAI.
Plan of Correction:	DON/RCC will meet weekly to ensure all new orders are reflected on the ISP/UAI for Home health orders.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months. Evidence: 1. Resident #3 admitted 10-03-2016. Resident #3?s most current ISP on file was dated 06-28-2020. Staff #1 confirmed that Resident #3?s ISP was not updated at least once every 12 months.
Plan of Correction:	DON/RCC/ Administrator will meet at the beginning of each month to ensure all ISP are up to date according to their due date or if conditions have changed. Due dates will be kept in a calendar as well as a binder with all the ISP/UAI filed for the month they need to be completed.
Standard #:	22VAC40-73-560-D
Description:	Based on record review and interview with staff, the facility failed to ensure copies of all agreements between the facility and the resident and official acknowledgment of required notifications, signed by all parties involved, shall be retained in the resident's record. Evidence: 1. Resident #1?s ?Residence and Service Agreement? and ?New Resident Orientation? were not signed by all parties involved as there was no resident or responsible party signature. 2. Resident #6?s ?Residence and Service Agreement?, ?New Resident Orientation?, and ?Acknowledgement of Receipt of Disclosure Statement? were not signed by all parties involved as there was no resident or responsible party signature.
Plan of Correction:	Marketing Director will ensure all documentation is signed prior to move-in. Administrator will look over all paperwork once completed to make sure everything is completed
Standard #:	22VAC40-73-710-E
Description:	Based on record review and interview with staff, the facility failed to ensure restraints were used in accordance with the resident's service plan. Evidence: 1. Resident #1 admitted 12-07-2021 to the safe, secure environment (SSE). Resident #1?s physician?s orders dated 12-07-2021 documented, ?1/2 Side Rails for Safety and Fall Prevention: Define the edge of the bed and provides comfort and security.? Resident #1?s individualized service plan (ISP) dated 12-07-2021 documented, ?side rails for hospital bed 12-13-21? but did not document the use of the restraints. 2. Resident #2 admitted 12-15-2021 to the facility. Resident #2?s physician?s orders dated 01-14-2022 documented, ?Hospital Bed Semi-electric with ? side rails?. Resident #2?s ISP dated 12-30-2021 did not document the resident?s side rails nor the use of the restraints.
Plan of Correction:	DON/RCC will audit all charts for residents with restraints to ensure restraint orders are in place and that ISP are up to date with restraints. DON/RCC and Administrator will meet weekly to make sure all new orders for restraints are up to date on ISPs.