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: Aug. 8, 2023

Complaint Related: No

Areas Reviewed:

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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-08-2023 ? 9:10am - noon The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 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, the facility failed to ensure prior to his admission to a safe, secure environment (SSE), the resident was assessment by a physician as being unable to recognize danger or protect his own safety and welfare. Evidence: Resident #1 admitted 1-13-2023 to the SSE. Resident #1?s Assessment of Serious Cognitive Impairment dated 1-10-2023 answered ?No? for the question, ?Is the individual named above unable to recognize danger or protect his/her own safety and welfare??; however, for placement in the SSE, the answer should be ?yes?.
Plan of Correction:	Form was corrected by MD. Moving forward Director of Marketing will ensure that forms are properly filled out moving forward.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, record review and interview with staff, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber?s instructions. Evidence: Resident #4?s Physician?s Orders dated June 2023 documented ?Lidocaine 5% patch; apply one patch topically to the affected area once daily? on 12 hours ? off 12 hours?. According to Staff #2 during the medication administration observation on 8-08-2023, the patch was to be removed on 8-07-2023 at 9:00 p.m. per the order and Medication Administration Record (MAR); however, the patch was still on during the morning medication pass at approximately 9:30 a.m. Staff #2 confirmed during the observation that Resident #4?s lidocaine patch was supposed to be removed the previous shift and was still there during the present shift on 8-08-2023. Staff #2 removed the patch and noted it on the August 2023 MAR.
Plan of Correction:	We will have a med tech meeting on 12/15/23 to go review with med techs.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and interview with staff, the facility failed to ensure that the date and time given and initials of direct care staff administering the medication was included on the medication administration record (MAR). Evidence: Resident #3?s Clonidine was reported as administered on 7-01-2023 by the RMA on staff; however, the staff didn?t sign off as having administered the medication. Staff #1 confirmed the RMA administered the medication.
Plan of Correction:	We had a med tech meeting with staff to review the importance of documentation. RCC will monitor on going to ensure staff are signing off.