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: Jan. 9, 2024 , Feb. 13, 2024 and Feb. 28, 2024

Complaint Related: No

Areas Reviewed:

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: 01/09/2024 11:25am to 11:37am, 02/13/2024 10:38am to 10:53am, 02/28/2024 3:45pm to 3:49pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/05/2024 regarding allegations in the area(s) of: Resident care and related services, medication administration Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-680-B
Description:	Based on facility self-report and interviews with staff, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. Per the facility self-report received 01/05/2024, staff #1 reported to staff #4 on 01/04/2024 that staff #2 had pre-pulled 9PM medications before shift change the previous night and on other occasions. Staff #4 contacted staff #3 and she also reported staff #2 had pre-pulled her 9PM medications, for approximately one month. 2. Per telephone interview with staff #3 on 01/16/2024, staff #2 was pre-pulling the 9PM medications, beginning in early December 2023. She reports staff #2 was removing the medication from the roll packs and narcotic cards and leaving the medications in medicine cups in the locked medication cart in the designated space for each resident. 3. Staff #2 confirmed in an interview on 02/13/2024 she had pre-pulled medications for the night shift coworkers for the month of December 2023, through January 3, 2024. She reported she removed all medications from the packaging, including narcotics, and left in medicine cups in the designated spaces for each resident in the locked medication cart. 4. Per written statement provided by staff #1 on 02/26/2024 and interview with staff #1 on 02/28/2024, staff #2 pre-pulled her shift?s medications on three occasions. She reported staff #2 would leave the medications in the cart, in the appropriate slot, to be administered by staff #1.
Plan of Correction:	1.) Staff #1, #2, and #3 received individualized education regarding the incident with corrective action. 2.) All Memory Care licensed practical nurses and the registered medication aide received in-service on medication administration per facility policies and practices. 3.) All Memory Care medication administration staff received a copy of the administration of medication policies and procedures for future reference and verbalized/demonstrated their knowledge of location of the policies and procedures manual location in the facility. 4.) All Memory Care med cart staff were monitored through a complete med pass to demonstrate their knowledge and compliance to policies and procedures regarding medication administration. 5.) Random audits of med passes have been completed since occurrence and will continue for 3 months. 6.) Memory Care Director has audited the med cart to ensure there are no pre-pulled medications placed in the cart. These random audits will continue for 3 months. [SIC]