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. 22, 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 22VAC40-90 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: 02/22/2023, 9:35am to 4:26pm 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: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection finding. 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 #:	22VAC40-73-100-C-2
Description:	Based on observations made during the medication cart audits, the facility failed to follow their infection control policy. EVIDENCE: 1. On medication cart A-1 resident #10 had a glucometer which was not labeled. The container for the glucometer was labeled. 2. On medication cart A-2 resident #11 had a glucometer which was not labeled. The container for the glucometer was labeled.
Plan of Correction:	The following is a summary of the Plan of Correction for Brookdale Bristol. This Plan of Correction is in regards to the Corrective Action Report dated February 22, 2023. This correction is not to be construed as an admission of or agreement with any findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding, nor have we identified any mitigating factors. ? On 03/08/23, the glucometers for residents #10 and #11 have been labeled with their names in addition to the containers in which they are kept. ? Training will be provided to all med-passers by HWD/designee regarding glucometers being properly labeled. ? Random audits of community?s medication carts will be conducted by HWD/designee for three months to verify compliance with community?s infection control guidelines. [SIC]
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that private pay Uniform Assessment Instruments (UAIs) were completed as required. EVIDENCE: 1. The UAIs dated 10/08/2022 for resident #2, 12/02/2022 for resident #4, 01/01/2023 for resident #6, 12/02/2022 for resident #7, 09/01/2022 for resident #8, and 09/08/2022 for resident #9 have documentation that medications are administered by professional nursing staff. These residents also receive medication administration from facility Registered Medication Aides (RMAs) who are considered laypersons on the UAI form.
Plan of Correction:	? For residents #2, #, #6, #, #7, #8, and #9 UAIs have been updated as of 03/10/23 to indicate medications will be administered by a ?layperson? instead of professional nursing staff? member. ? HWD and other staff with UAI assessment responsibility will be trained on appropriately identifying ?laypersons? as administering medications. ? HWD/designee will perform regular audits of UAI assessments to verify compliance with appropriate staff indication regarding medication administration. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on Individualized Service Plans (ISPs) for four of the nine resident files that were reviewed. EVIDENCE: 1. The UAI in the record for resident #6, dated 01/01/2023, identifies disoriented ? some spheres, some of the time, regarding orientation. The ISP in the record for resident #6, dated 01/05/2023, does not address these needs. 2. The UAI in the record for resident #7, dated 12/02/2022, identifies disoriented ? some spheres, some of the time, regarding orientation. The ISP in the record for resident #7, dated 12/30/2022, does not address these needs. 3. The UAI for resident #2, dated 10/08/2022, identifies bathing (human help only, physical assistance) and dressing (human help only, supervision) as needs. The ISP in the record for resident #2, dated 10/08/2022, does not address these needs. 4. The UAI in the record for resident #9, dated 09/08/2022, identifies bathing and dressing (human help only, supervision) as needs. The ISP in the record for resident #9, dated 09/16/2022, does not address these needs.
Plan of Correction:	? For residents #6 and #7, ISPs have been updated to address their times of disorientation as of 03/09/23. For resident #2, ISP have been updated on 03/09/23 to address bathing and dressing needs identified. For resident #9, ISP has been updated on 03/09/23 to address bathing and dressing needs identified. ? HWD and other staff with ISP and UAI assessment responsibility will be trained on appropriately addressing identified needs of residents. ? HWD/designee will perform regular audits ISPs to verify compliance in addressing need of residents. [SIC]
Standard #:	22VAC40-73-450-H
Description:	Based on observations made during the tour of the building and review of resident records, the facility failed to ensure the care and services specified in the Individual Service Plan (ISP) are provided to each resident. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident #12 was completed on 12/01/2022 and indicates he needs help with housekeeping. The ISP identifies housekeeping as a need which was identified on 12/18/2022. The facility states it will provide ?cleaning of personal dwelling and common area weekly as needed which includes but not limited to linen changes weekly and as needed.? When the two LI?s entered the room, it appeared to be cluttered and not clean. There was more than 25 pieces of mail scattered on the kitchen area counter tops and laying on the eyes of the working stove in this room. 2. The UAI for resident #13 was completed on 05/10/2022 and indicates he needs help with housekeeping. The ISP identifies housekeeping as a need which was identified on 05/10/2022. The facility states it will provide ?cleaning of personal dwelling and common area weekly and as needed which includes but not limited to linen changes weekly and as needed.? When LI entered resident #13?s room it was found to have large pieces of uneaten food on the floor in front of the resident?s bed, house slippers were scattered about the room and the kitchenette area was cluttered with dirty dishes.
Plan of Correction:	? For resident #12, apartment will be appropriately cleaned, including linen changes. Staff will work with resident and/or family to remove clutter and/or organize personal items in apartment. For resident #13, apartment will be appropriately cleaned, including linen changes. Uneaten food and dirty dishes will be removed. Resident will be assisted in organizing and putting away personal items including house slippers and other clothing items. ? Training will be provided to housekeeping and care staff on proper cleaning methods apartments, as well as offering routine assistance with removing clutter from residents? personal space as identified on individual plans of care. ? Executive Director/designee will conduct random audits to verify directed cleaning methods are acceptable and provided as scheduled. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the facility, the facility failed to keep all interior areas of the building in good repair and clean. EVIDENCE: 1. On hallway A-1 outside of the activity room, the transition strip from the laminate flooring to the carpet had a piece of carpet approximately 12 inches long that was raised and torn. This area could present a trip hazard or cause a walker or cane to become caught/lodged in the area. 2. On hallway B-3 at the door in front of the stairway located next to the elevator, there was a large (eight to 10 inches) brownish colored stain on the carpet. 3. On the second floor, on hallway A-2 outside of the medication room, the transition strip from the laminate flooring to the carpet had a piece of carpet raised up approximately 18 inches long; this could present a trip hazard. 4. Room #303 had a handwritten sign hanging on the door, ?watch the carpet!! Coming up?. Inside the room at the transition strip from the laminate flooring to the carpet, there was a large area approximately 18-24 inches long which was coming up from the floor and could present a trip hazard. The carpet appeared to have staples in it to hold it down.
Plan of Correction:	? The flooring/transition strip concerns stated in items 1, 3, and 4 have been addressed/repaired by the facility maintenance staff on 03/03/23. The facility?s flooring contractor has been contacted to provide a long-term repair/solution to this concern. The stain described in item 2 and been cleaned/removed. ? Associates will be provided in-service on floor care, which will include appropriate cleaning methods and reporting repair needs. Maintenance Director will conduct weekly audits of common area flooring with focus on transition locations. Apartment and common area carpet cleanings will be assigned on a rotating weekly schedule. ? Executive Director/designee will conduct random audits to verify interior of building is clean and in good condition. [SIC]