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: Oct. 3, 2023 and Nov. 1, 2023

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 10/03/2023 10:08am to 3:10pm and 11/01/2023 9:08am to 4:29pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 7 Number of interviews conducted with residents: 0 (1 interview with a resident?s family member) Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on review of resident records, the facility failed to ensure that six months after placement of the resident in the safe secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. EVIDENCE: 1. Resident #1 was placed in the special care unit on 01/19/2021. The six-month review of appropriateness occurred on 05/12/2021. There were subsequent reviews on 01/23/2023 and 07/19/2023. There was no annual review in 2022 documented in the record for resident #1. 2. Resident #5 was placed in the special care unit on 08/21/2020. The first review of appropriateness occurred on 05/12/2021, more than six months after resident #5 was placed in the special care unit. The next review occurred on 08/24/2022; more than 12 months had elapsed since the previous review.
Plan of Correction:	1.) Although the annual review in 2022 of resident #1 and the six month of 2021 and annual review of 2022 on resident #5 cannot be corrected the facility will ensure going forward that the six months after placement and the annual review of the appropriateness of continued residence in the special care unit will be performed on time for each resident. 2.) All residents? files have the potential to be affected by the deficient practice. 3.) All resident files have been audited to ensure the correct review of the appropriateness of continued residence in the special care unit are of correct time frame. 4.) The Memory Care Director will conduct monthly audits on resident files to ensure the appropriate review of the appropriateness of continued residence in the special care unit is done on time. [SIC]
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure the physical examination and report shall contain a description of the person's reactions to known allergies. EVIDENCE: 1. The report of resident physical examination for resident #3 completed 01/09/2023 identifies penicillin as a known allergy; a description of resident #3?s reaction to penicillin is not included on the report. 2. The report of resident physical examination for resident #5 completed 08/21/2020 identifies sulfa as a known allergy; a description of resident #5?s reaction to sulfa is not included on the report.
Plan of Correction:	1.) Reactions to known allergies for both resident #3 and #5 have been identified and added to the physical examination and report for each resident and placed in each resident?s record. 2.) There is a potential for the same practice to happen for all new admissions due to deficient practice. 3.) All resident files were audited to ensure all reactions to known allergies were present in their physical examination and report. 4.) The Memory Care Director will conduct audits to ensure that all reactions to known allergies will be identified on the physical examination and report of all new admissions. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on comprehensive individualized service plans (ISPs) for three of the six resident files that were reviewed. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident #2 completed 01/05/2023 identifies disoriented ? some spheres, some of the time with the following spheres affected: place, time and situation. The ISP for resident #2 completed 01/09/2023 does not address the spheres of place and situation. 2. The UAI for resident #3 completed 02/02/2023 identifies disoriented ? some spheres, some of the time with the following spheres affected: place and time. The ISP for resident #3 completed 02/02/2023 does not address the sphere of place. 3. The UAI for resident #5 completed 02/20/2023 identifies disoriented ? some spheres, all the time with the following spheres affected: place, time and situation. The ISP for resident #5 completed 02/20/2023 does not address the spheres of place and situation.
Plan of Correction:	1.) The ISP for resident #2 has been updated to address the spheres of place and situation. The ISP for resident #3 has been updated to address the sphere of place. The ISP for resident #5 has been updated to address the spheres of place and situation. 2.) All residents have the potential for the same practice to happen due to deficient practice. 3.) All current ISPs have been audited to ensure that all needs identified on the current UAI have been addressed. 4.)The Memory Care Director will monthly audits all new ISPs to ensure that all identified needs are addressed on comprehensive individualized services plans (ISPs). [SIC]
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual, and to maintain evidence of this review via written acknowledgment of having been so informed, which shall include the date of the review, in the resident's record. EVIDENCE: 1. Resident #1 was admitted to the facility on 01/19/2021. Acknowledgement of the review of resident rights for resident #1 was signed and dated by the responsible individual on 01/28/2021. No further documentation verifying annual review of resident rights and responsibilities were observed in the record for resident #1. 2. Resident #2 was admitted to the facility on 08/22/2021. Acknowledgement of the review of resident rights for resident #2 was signed and dated by the responsible individual on 08/22/2021. No further documentation verifying annual review of resident rights and responsibilities were observed in the record for resident #2. 3. Resident #6 was admitted to the facility on 08/21/2020. Acknowledgement of the review of resident rights for resident #6 was signed and dated by the responsible individual on 08/21/2020. No further documentation verifying annual review of resident rights and responsibilities were observed in the record for resident #6.
Plan of Correction:	1.) The rights and responsibilities of residents in assisted living facilities have been reviewed with the legal representative or responsible individual with written acknowledgement including the date of review for resident #1 and #2 and have been placed in resident?s record. Resident #6 is no longer a resident on assisted living with discharge date of 07/24/23. 2.) All residents have the potential to be affected by the deficient practice. 3.) All residents that were due an annual review of rights and responsibilities in assisted living facilities have been reviewed with their legal representative or responsible individual with a signed acknowledgement placed in their records. 4.) The Memory Care Director will conduct monthly audits to ensure that the rights and responsibilities of residents in assisted living facilities will be reviewed with each resident or his legal representative or responsible individual and have written acknowledgement of having been so informed which will include the date of the review and will be placed in the resident?s record. [SIC]