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: Nov. 22, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 11-22-2022 10:50 ? 11:15 a.m.; 4-20-2023 8:45 ? 10:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 11-09-2022 regarding allegations in the areas of: Admission, Retention and Discharge of Residents; Resident Care and Related Services; and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 75/72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility and review of records along with staff interviews. Number of resident records reviewed: 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review and interview with staff, the facility failed to ensure that prior to his admission to a safe, secure environment (SSE), the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #2 admitted 11-03-2022 to the SSE. Resident #2?s ?Assessment of Serious Cognitive Impairment? documented ?No? under the question, ?Is the individual named above unable to recognize danger or protect his/her own safety and welfare??; however, the resident was placed in the SSE as of 11-03-2022 and remained there until Resident #2?s discharge on 2-28-2023. 2. Staff #1 acknowledged during interview that Resident #2 had been placed in the SSE and that the physician?s assessment of Resident #2 did not assess the resident as unable to recognize danger or protect his own safety and welfare.
Plan of Correction:	Sales Director will look over all secure environment paperwork prior to move-in. DON will audit all current resident?s charts to ensure proper paperwork is in place.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview with staff, the facility failed to ensure a person?s physical exam contained a description of the person?s reactions to any known allergies. Evidence: Resident #2?s ?Report of Resident Physical Examination? dated 10-27-2022 documented, ?Codeine PCN [penicillin] and eggs? as allergies; however, no reactions were described on the physical exam.
Plan of Correction:	Sales Director and DON will ensure all new admissions have description of reactions to any known allergies prior to admission.
Standard #:	22VAC40-73-325-B
Description:	Based on record review and interview with staff, the facility failed to ensure the fall risk rating was updated after a fall. Evidence: Per Staff #2?s written statement of a resident falling on the floor, Resident #2 had a fall on 11-09-2022. Staff #1 confirmed during interview that Resident #2 had fallen on 11-09-2022 and sustained no injuries; however, no Fall Risk Rating was completed for the fall.
Plan of Correction:	DON/RCC will audit all charts for fall risk assessment, all residents will be scheduled in a calendar for when assessments are due. Administrator will audit monthly.
Standard #:	22VAC40-73-460-B
Description:	Based on record review and interview with staff, the facility failed to ensure personalization of care and services were tailored to the resident?s circumstances including prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. Resident #1 admitted into care at 100 years old on 11-09-2022. Resident #1?s ?Report of Resident Physical Examination? dated 11-01-2022 documented the resident has ?senile degeneration of brain?. Resident #1?s UAI (dated 10-26-2022) and ISP (dated 11-09-2022) documented the resident was wheelchair bound and admitted under hospice care. 2.Routine round checks were scheduled every 30 minutes, and the resident?s log showed 3:30p.m. as the last documented time. Rounds conducted by Staff #5 that took place on 11/09/2022 found the resident was not on the unit at approximately 5:55 p.m. Resident #1 was found approximately 50 minutes later by Staff #3 and #4 at the bottom of the flight of stairs outside of the memory care unit (after staff reviewed the floor video). 3.Statements from each of the four staff working on 11-09-2022 document that staff #3 turned the door alarm off after it sounded, but did not check the exits upon hearing the door alarm. Approximately 50 minutes later it was discovered that Resident #1 exited a door on the special care unit and fell down a flight of 18 stairs. The resident was transported to a local hospital by emergency response personnel.
Plan of Correction:	-All staff have been in-serviced and trained on elopements, door alarms, and what to do in emergency situations. -All nursing staff have been in-serviced on the importance of 30 min checks and documentation. -Going forward all staff are trained on elopement policy, what to do when alarms go off on memory care, and documentation. -Elopement drills are conducted monthly.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to provide supervision of resident care including attention to specialized needs, such as prevention of falls and wandering. Evidence: 1.Staff #2 was assigned oversite of Resident #1 who was admitted 11-09-2022 to the special care unit (SCU). 2.Staff #1 confirmed Staff #2 did not provide constant staff oversight to ensure safety of Resident #1. Resident #1 who was in a wheelchair, left the special care unit through one of the two exits via stairwell with a delayed egress system and alarm. The resident wheeled herself into a stairwell where she exited the wheelchair and fell down a flight of 18 stairs. Video surveillance reviewed by staff and the staff incident report noted that resident #1 was on the floor at the bottom of the stairwell for approximately 50 minutes. Staff statements documented that upon hearing the alarm, a staff member (staff #3) turned it off and did not immediately look for the source of the alarm.
Plan of Correction:	-All nursing staff are in-serviced upon hire on specialized needs, fall prevention, wandering, & elopement.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview, the facility failed to implement a written plan for medication management, including standard operating procedures. Evidence: 1. The facility?s medication management plan dated August 2011 documented under facility?s documentation leave policy: ?Medications not given 1. Staff member should circle his or her initials on the front of the MAR and document on the back why medication was not administered?? 2. Resident #1?s November 2022 Medication Administration Record [MAR] was signed by Staff #6 as having administered Oxycodone HCL 5 mg tablet on 11-10-2022 at 5:00 p.m.; however, the resident not in the facility on 11-10-2022. The MAR documented, ?**RESIDENT OUT OF FACILITY 09 Nov 2022 TO 21 Nov 2022: **? 3. Staff #1 confirmed the documentation did not follow standard operating procedures for medication documentation by not circling staff?s initials and documenting why the medication was not administered.
Plan of Correction:	DON/RCC will have in-service with medication aide as well as schedule refresher course.