VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Memory Care at Bristol
301 Village Circle
Bristol, VA 24201
(276) 477-5334

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Nov. 10, 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

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: 11/10/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Begin: 10:20 am: End: 6:20pm 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 Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-A
Description:	Based on observations and staff interview, the facility failed to maintain at least two direct care staff members awake and on duty and for every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit. EVIDENCE: 1. The LI observed only two direct care staff persons; Staff #5 and #6; on the special care unit from 2:15pm-2:35pm; 2:44pm-2:47pm; 2:54pm-3:03pm. 2. Staff #5 and #6 confirmed they were the only two direct care staff persons available on the special care unit from the above-mentioned times.
Plan of Correction:	1. The new Director of Memory Care and scheduler have both been educated regarding the staffing requirements. 2. The facility is at risk for the same deficient practice. 3. Staff breaks will be scheduled going forward, to ensure the required staff are on the unit. 4. The Administrator or Memory Care Director will audit weekly to ensure appropriate staffing. [sic]
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to maintain verification that a staff person received a copy of his/her current job description. EVIDENCE: 1. Staff #3 was hired on 9/20/22. According to Staff #4 there was no job description available in Staff #3?s file.
Plan of Correction:	1. Copy of Staff #3?s Job Description was obtained and placed in file. 2. All have the potential to have job descriptions missing from their files. 3. All records were reviewed to ensure there is a signed job description on file for each person. 4. Human Resources will review each new hire?s record to ensure job descriptions are maintained. [sic]
Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submit the results of a tuberculosis risk assessment. EVIDENCE: 1. Staff #2 was hired on 9/30/22. According to Staff #4 there was not a tuberculosis risk assessment available in Staff #2?s file.
Plan of Correction:	1. A tuberculosis risk assessment was conducted for Staff #2. 2. All team members have the potential to be affected by the deficient practice. 3. All team member files were audited to ensure risk assessment results were present and conducted if needed. 4. Human Resources Manager will audit files to ensure risk assessments are included for any new hire and team members done annually. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to obtain the following personal and social data prior to or at time of the admission for one resident. EVIDENCE: 1. Resident #7 was admitted to the facility on 6/1/22. The following areas were left blank on Resident #7?s personal and social data: local department of social services, other agency, previous mental health, current behaviors, and substance abuse history.
Plan of Correction:	1. Resident Personal Social Data form for resident #7 was incomplete. Memory Care Director will meet with family to complete the form. 2. All residents have the potential to be affected by the same practice. 3. All resident records will be reviewed to ensure all forms are complete. 4. The Administrator or designee will do a final review [sic]
Standard #:	22VAC40-73-390-C
Description:	Based on resident record review, the facility failed to update the residential agreement with the facility whenever there are changes to any policy or information referenced. EVIDENCE: 1. On 6/1/22, a new licensee assumed responsibility for this facility. Residents #5, #7, and #8 were residing at this facility prior to the 6/1/22 takeover. Resident #5, #7, nor #8 had any signed and dated documentation in their files to show the update or change to the original agreement regarding the new licensee.
Plan of Correction:	1. An addendum to the residential agreement with the facility will be sent to each resident and/or resident representative to extend the agreement to include the new licensee. 2. All residents have the potential to be affected by the same deficient practice. The agreement addendum will be sent to all residents and/or resident representatives. 3. Education provided to the Admissions Director regarding new ownership. 4. An audit will be conducted to ensure appropriate agreement is in place for new admissions. [sic]
Standard #:	22VAC40-73-410-A
Description:	Based on resident record review, the facility failed to include a signed and dated document to show that residents and/or their responsible party had received orientation to the facility for four residents. EVIDENCE: 1. Resident #5 was admitted to the facility on 8/22/21. 2. Resident #6 was admitted to the facility on 10/26/22. 3. Resident #7 was admitted to the facility on 6/1/22. 4. Resident #8 was admitted to the facility on 6/1/22. 5. There was no was no documentation in the above mentioned resident?s files to show the resident or his/her responsible party had received orientation to the facility.
Plan of Correction:	1. Residents 5, 6, 7 and 8 were contacted and orientation was provided, and questions were reviewed. 2. All residents have the potential to be affected by the deficient practice. 3. Administrator provided education to the new Memory Care Director to create new admission packets to include documentation related to unit orientation for new residents and/or their family. 4. Audits will be conducted for new admissions. [sic]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the building, the facility failed to have the menu for the current week dated and posted. EVIDENCE: 1. The menu posted in the dining area was dated as ?Week 4, Sunday-Saturday?, but no dates were specified.
Plan of Correction:	1. When posted, menus will have a date associated with the week. 2. All were potentially affected. 3. Administrator provided education to the Dietary Manager. 4. The Memory Care Director will conduct monthly audits to ensure corrective measures remain in place. [sic]
Standard #:	22VAC40-73-650-C
Description:	Based on review of resident records, the facility failed to have a physician order reviewed and signed within 14 days for one resident. EVIDENCE: 1. Resident #10 was prescribed Buspirone tablet, 15 mg, one tablet by mouth three times daily on 2/28/22. On the date of the inspection (11/10/22), this order had not been signed.
Plan of Correction:	1. Provider who ordered medication for resident #10 is no longer seeing residents at this Center. The order has been discontinued and re-ordered by the current provider. 2. All provider orders have the potential to be affected by the deficient practice. 3. Providers will be re-educated regarding the 14 day signature. The Memory Care Director will perform an audit of all records to ensure all orders are signed. 4. An audit will be conducted monthly to ensure all orders are signed as appropriate. [sic]
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations made during the tour of the building, the facility failed to store all medications in a locked storage area. EVIDENCE: 1. When LI was walking by the medication cart there were several medication cards laying on top of the medication cart to include: Metoprol Suc Tab, 25 mg ER; Folic Acid 1,000mcg; Zinc Sulfate 220mg; Buspirone 5mg; Buspirone 10mg; Losartartan 50mg; Mucus Relief 600mg ER; Furosemide 20mg; Acetaminophen 325mg; Asprin 81mg; Docusate Sodium 100mg; Dutasteride .5mg. These medications were left unattended and unlocked on the date of the inspection; 11/10/22.
Plan of Correction:	1. Education will be provided to the nurse. 2. There is a potential for the same practice to happen due to deficient practice. 3. Education will be provided to all licensed team members. 4. Memory Care Director will conduct periodic audits throughout the month to ensure no medications are left unattended. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and the medication cart audit, the facility failed to administer medications consistent with the standards outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDNECE: 1. Bre Ellipta Inhaler 100-25, one puff by mouth daily for Resident #6 was found in the medication cart with no open date. 2. Fluticasone Spray 50mcg one spray in each nostril every day for Resident #11 was found in the medication cart with no open date. 3. Dorzolamide Solution 2% eye drops, one drop in each eye twice daily for Resident #12 was found in the medication cart with no open date.
Plan of Correction:	1.All medications for residents #6, #11 and #12 were correctly dated. 2. All resident medications have the potential to be affected by the same deficient practice. 3. Education will be provided for all licensed team members. 4. The Memory Care Director will audit medication carts four times monthly to ensure medications are properly maintained. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to keep all furnishings, fixture, and equipment clean and in good repair and condition. EVIDENCE: 1. Six of the dining room chairs were found to have dark brown stained areas on the seat cushions of the chairs. LI only looked at six chairs because the remainder of the chairs were occupied by residents. 2. The area under the sink off of the dining room was found to have a dried brown substance approximately one foot by one foot in area which has left a stain.
Plan of Correction:	1. (A) Chairs were cleaned by housekeeping staff. Administration working on a plan to have seats cushions re-upholstered. (B) Housekeeping will clean under the sink in the memory care diet kitchen area. 2. All areas have the potential to be impacted. 3. An audit of all like furniture and sink spaces will be conducted and issues addressed. 4. Housekeeping Director will conduct a monthly audit to ensure furniture and spaces under sink is clean. [sic]