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:

Complaint Related: No

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.