VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Bristol
375 Liberty Place
Bristol, VA 24201
(276) 669-1111

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Feb. 10, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

Two licensing inspectors conducted an unannounced mandated license renewal inspection at Brookdale Bristol on 02/10/2020. The inspection started at 10:00 am and concluded at 3:32 pm. Required postings were checked.A tour of the building was completed. Resident interviews were conducted. A sample of resident and staff files were reviewed. The medication cart and medication administration records were reviewed. Lunch and snacks were observed being served. Staff and resident interactions were observed. An exit meeting was held wit the administrator and other key staff on 02/10/2020 and at that time an opportunity was given to find items that were not available in files. As a result of this inspection 3 violations are being cited. Please develop a plan of correction for each of the cited violations along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (02/23/2020) of receipt. If you have any questions or concerns please contact your inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observations made during the noon medication pass the facility failed to adhere to their infection control policy. EVIDENCE: 1. Staff # 2 entered Resident # 11?s room to check his blood glucose level prior to lunch time. Staff # 2 placed the glucose monitoring supplies on a side table located next to Resident # 11's recliner where he was sitting and did not place a protective barrier on the side table.
Plan of Correction:	1. On 02/10/2020, Staff # 2 has been re-trained for proper use of a protective barrier when using a resident's glucose monitoring equipment and/or supplies. 2. Retraining will be conducted for licensed and registered staff competed by the HWD/designee regarding the community's infection control guidelines. 3. Random audits of the community's medication carts will be conducted by the Health and Wellness Director/designee for three months to verify compliance with the community's infection control guidelines. [sic]
Standard #:	22VAC40-73-260-A
Description:	Based on review of staff records including first aid and CPR certifications, the facility failed to ensure one direct care aide in a sample of five maintained certification in first aid and CPR. EVIDENCE : 1. Staff #3 was hired at the facility on 12/31/2018. She is a certified nursing assistant and was hired for direct care. She did not have first aid or CPR certification.
Plan of Correction:	1. Staff # 3 will receive an updated certificate on CPR and First Aid by a facilities instructor. The facilities instructor has been contacted to schedule a class for the community. 2. The Business Office Manager/designee will audit direct care associate files for appropriate First Aid/CPR certifications and schedule a course as necessary. 3. Business Office Manager/designee will audit 25% of personnel training files quarterly to verify compliance with this requirement. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on review of the medication management plan and review of medication carts, the facility failed to implement a medication management plan to include all information required by the regulations. EVIDENCE: 1. The A side medication cart was found to have three round white pills, one three quarter size blue oblong pill, and two white oval pills found in the medication cart drawers laying loose.
Plan of Correction:	1. The six pills found in the medication cart have been appropriately disposed as of 02/10/2020. 2. Retraining will be conducted for licensed and registered staff and medication aides to review the community's medication plan. This will include instruction on completing medication cart audits, specifically to include identifying loose pills. 3. Random audits of the community's medication carts will be conducted by the Health and Wellness Director/designee for three months to verify compliance with the community's infection control guidelines. [sic]