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 20, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 4-20-2023, 10:01 ? 11:29 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report incident was received by VDSS Division of Licensing on 2-28-2023 regarding allegations in the areas of Admission, Retention and Discharge of Residents and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 72 Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-40-A
Description:	Based on record review, the licensee failed to ensure compliance with the facility's own policies and procedures. Evidence: 1. The ?Fall Management Policy? dated 2009-2020 documented, ?An individualized service plan [ISP] is maintained and includes: a. Identified fall risk factors, b. Identified realistic and attainable goals and interventions, c. Initiation on admission and updates every six months, with a significant change in status in condition, and post-fall?. 2. Resident #1?s ISP dated 9-15-2022 documented the resident as a ?fall risk?; however, no updated fall risk ratings were completed in March 2023 at six months, nor was an update completed post fall on 4-17-2023 which was seen on Resident #1?s ?Charting Notes?. 3. Additionally, a final incident report received from Staff #1 on 3-08-2023 documented that on 2-26-2023, ?Agency staff heard a loud fall, went to check everyone and that?s when [Agency Staff] saw [Resident #1] standing at [Resident #1?s] door? [Resident #1] stated to the aide that [Resident #1] fell and hit [Resident #1]?s head?? 4. There were no updates for risk ratings either fall on 2-26-2023 nor 4-17-2023 were documented in Resident #1?s ISP.
Plan of Correction:	DON/RCC will audit all charts for Fall risk assessments, all residents will be scheduled in a calendar for when assessments are due. Administrator will audit monthly.
Standard #:	22VAC40-73-325-B
Description:	Based on record review and interview with staff, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: Resident #1 had falls that occurred on 2-26-2023 per incident report received by Staff #1, and 4-17-2023 per the resident?s Charting Notes; however, no fall risk ratings were completed for the resident falls.
Plan of Correction:	DON/RCC will audit all charts for Fall risk assessments, all residents will be scheduled in a calendar for when assessments are due. Administrator will audit monthly.
Standard #:	22VAC40-73-450-H
Description:	Based on record review and interview with staff, the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident. Evidence: 1. Resident #1?s ISP dated 9-15-2022 documented under Safety Checks, ?Staff to check on resident every 2 hours or as needed to maintain safety and well-being. Staff to ensure resident call bell is in resident?s reach.? 2. Round logs provided by Staff #1 dated 3-15-2023 to 6-13-2023 demonstrated that two-hour checks that were not being completed; primarily not completed during overnight hours. A sample showed that on 5-04-2023, only two checks were documented, as well as four checks on 5-16-2023, and four checks on 4-15-2023. 3. Staff #1 acknowledged during interview that two-hour checks on Resident #1 had not been conducted consistently.
Plan of Correction:	Timers have been put in place to go off every 2 hours. (as of 6/9/2023) Staff will be in-service on the importance of safety checks and documentation by DON/.
Standard #:	22VAC40-73-650-B
Description:	Based on record review, the facility failed to ensure physician?s orders identified the diagnosis, condition, or specific indications for administering each drug. Evidence: Resident #1?s Physician?s Orders dated 3-06-2023 did not identify diagnosis, condition, or specific indications for the following medications: Acidophilus capsule, Aspirin, Calcium, Dicyclomine, Escitalopram, Fexofenadine, Namzaric, Potassium CL, Preservision Areds, and Zolpidem Tartrate. Staff #1 acknowledged during interview that Resident #1?s physician?s orders did not contain the identification for the medications.
Plan of Correction:	DON will call MD office to have orders updated with diagnosis. DON/RCC will audit all charts to ensure diagnosis is on all orders.
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?s prescriber?s instructions. Evidence: 1. Resident #1?s blood pressure orders written 8-19-2022 are as follows: ?Check BP [blood pressure] prior to giving Entresto doses. Hold if BP is below 110, recheck BP 2 hours later. If BP systolic is >120, give entresto? and is scheduled at 9:00 a.m. and 7:00 p.m. A second order written 9-08-2022 documented, ?Check blood pressure when giving her entresto doses, repeat in two hours for both morning and evening dose? and is scheduled at 11:00 a.m. and 9:00 p.m. 2. Resident #1?s Charting Notes document the following regarding late blood pressure checks: A. 5/25/23, 11:30 a.m.: ?BP taken a few minutes late due to working with another resident?; B. 4-21-2023 11:32 a.m.: ?B/S [sic] was taking [sic] late due emergency issues going on with another resident?; C. 4-17-2023 11:36 a.m.: ?B/P was taken late due to assisting another resident?; D. 3-19-23 12:40 pm: ?B/P was taking 21 minutes late this afternoon due to med tech assisting another resident?
Plan of Correction:	DON will have in-service with Medication aides to make sure they are aware that they do not have an hour before or after scheduled time like normal. Timers have been put in place for scheduled BP times. (as of 6/9/2023)
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: 1. Resident #1?s December 2022 MAR did not include diagnoses, conditions, or specific indications for the following drugs: A. Acidophilus capsule; B. Aspirin 81 mg; C. Lexapro 20 mg; D. Fexofenadine HCL 180 mg; E. Namzaric 28-10 mg; F. Potassium CL ER 10 meq; G. Preservision AREDS; H. Vitamin D3; I. Clonidine 0.1 mg; J. Genteal Tears; K. Systane PF Vials; L. Zolpidem Tartrate 5mg.
Plan of Correction:	DON will call MD office to have orders updated with diagnosis. DON/RCC will audit all charts to ensure diagnosis is on all orders and fax diagnosis to pharmacy to have MAR updated.