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: July 29, 2022

Complaint Related: No

Areas Reviewed:

? 22VAC40-73 GENERAL PROVISIONS ? 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES ? 22VAC40-73 PERSONNEL ? 22VAC40-73 STAFFING AND SUPERVISION ? 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ? 22VAC40-73 RESIDENT CARE AND RELATED SERVICES ? 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 63.2 GENERAL PROVISIONS ? 63.2 PROTECTION OF ADULTS AND REPORTING ? 63.2 LICENSURE AND REGISTRATION PROCEDURES ? 63.2 FACILITIES AND PROGRAMS ? 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES ? 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION ? 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/20/22; 8:30 a.m. ? 12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, 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 #3 admitted 5-02-2022. Resident #3?s Uniform Assessment Instrument (UAI) dated 4-15-2022 documented resident uses a walker to ambulate; however, Resident #3 is non-ambulatory and uses a wheelchair per the resident?s ISP dated 7-18-2022.
Plan of Correction:	DON will complete audit on all UAIs to ensure they are up to date and moving forward all UAIs will be updated within 30 days of significant change in condition.
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 and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #2 admitted 12-31-2019. Resident #2?s uniform assessment instrument (UAI) dated 12-30-2021 documented resident uses wheelchair ?mechanical help? and for mobility ?mechanical help, wheelchair?; however, the resident?s ISP dated 7-5-2022 does not address wheeling or mobility assistance. 2. Resident #6 admitted 11-01-2001. Resident #6?s UAI dated 1-28-2022 documented no assistance with bathing or dressing; however, the resident?s ISP dated 7-27-2022 documented ?unable to safely bath independently; Gather necessary supplies. Explain procedure to Resident. Cue Resident to assist where he/she can...? for bathing and ?unable to dress independently; Staff will supervise Resident with dressing, allowing maximum participation from Resident, and putting on ted hose in the morning and removing at night? for dressing. The UAI also said no assistance with toileting is needed; however, the ISP documented, ?supervision with toileting; Cue Resident and direct to bathroom every 2 hours and as needed. Use proper incontinence products?? 3. Resident #7 admitted 1-30-2020. Resident #7?s UAI dated 5-02-2022 documented resident uses rollator walker for walking; however, walking assistance with a rollator walker is not addressed on the ISP dated 5-02-2022. 4. Resident #9 admitted 9-20-2021. Resident #9?s UAI dated 8-13-2021 documented the resident uses a wheelchair; however, use of a wheelchair is not documented on the resident?s ISP dated 2-06-2022.
Plan of Correction:	DON will complete audit on all ISPs to ensure they are up to date and moving forward all ISPs will be updated within 30 days of significant change in condition and yearly.
Standard #:	22VAC40-73-520-I
Description:	Based on record review, the facility failed to ensure the written schedule of activities included the hour of the activity. Evidence: During the months of June and July 2022, there was no hour of activity listed on the activity schedule for the following dates: June 5, July 2, July 16, July 30, and July 31.
Plan of Correction:	Activities Director will ensure all activity calendars have the time and date each day for all activities.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. An incident report received by the facility to the regional licensing office on 7-20-2022 documented that ?Agency RMA [registered medication aide] gave wrong medication to the above-named resident.? 2. Hospital documentation from 7-20-2022 documented, ?Tonight in the last couple of hours patient [Resident #3] was incorrectly given another patient?s medications, these are Mucinex 60mg, fiberlax, melatonin 5mg, rosuvastatin 40mg and calcium?? 3. Staff #1 confirmed Resident #3 was administered medications not in accordance with the physician?s or other prescriber?s instructions.
Plan of Correction:	Facility notified agency of medication error and RMAs from Brighter Living received in-service on medication administration and The Five Rights of Medication Administration.