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: March 19, 2024

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: 02/29/2024 9:54am to 3:56pm and 03/01/2024 9:25am to 5:13pm 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 14 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 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 #:	22VAC40-73-210-D
Description:	Based on a review of staff records and interview with staff, the facility failed to ensure for medication aides, completion of continuing education required by the Virginia Board of Nursing for each medication aide employed by the facility. EVIDENCE: 1. Per documentation in the record for staff #2, staff #2 most recently completed the Registered Medication Aid 4 Hour CE Refresher Course on 08/30/2022. 2. Per interview with staff #6, staff #2 has not completed the four-hour refresher course since 08/30/2022. 3. Per 18VAC90-60-100, registered medication aides are to renew registration each year and as part of the renewal are to attest to completion of a refresher course in medication administration offered by an approved program.
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 March 01, 2024. 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. ? Staff #2 has been scheduled to receive Registered Medication Aid 4 Hour CE Refresher Course on 03/20/2024. ? An additional course has been scheduled for 06/05/2024 to meet requirement for other RMA associates. ? A record of RMA course completions will be maintained in the individual personnel records located in the community business office. ? The Executive Director or designee will complete random routine audits of required training records through 06/30/2024 to ensure compliance. [SIC]
Standard #:	22VAC40-73-260-A
Description:	Based on observations made during a review of staff records and interview with staff, the facility failed to ensure each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. EVIDENCE: 1. The most recent first aid certification observed in the record for staff #2 expired 11/2022. 2. Per interview with staff #6, staff #2 does not have a current first aid certification.
Plan of Correction:	? Staff #2 has been scheduled to complete an approved First Aid course on 04/03/2024. ? An audit of other appropriate personnel records has been completed by 03/08/2024 to ensure no other associates are out of compliance. ? CPR/First Aid training is scheduled to be provided for other associates needing CPR/First Aid training renewal on 04/03/2024. ? The Executive Director or designee will complete random audits of CPR/First Aid certifications through 06/30/2024. [SIC]
Standard #:	22VAC40-73-310-B
Description:	Based on a review of resident records, the facility failed to maintain verification of a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual resident and his or her legal representative, if any, for five of the resident records reviewed. EVIDENCE: 1. Resident #2 was admitted to the facility on 05/18/2022 and there was no verification/acknowledgement of the required interview. 2. Resident #5 was admitted to the facility on 02/10/2021 and there was no verification/acknowledgement of the required interview. 3. Resident #6 was admitted to the facility on 02/24/2016 and there was no verification/acknowledgement of the required interview. 4. Resident #7 was admitted to the facility on 12/30/2020 and there was no verification/acknowledgement of the required interview. 5. Resident #8 was admitted to the facility on 06/08/2021 and there was no verification/acknowledgement of the required interview.
Plan of Correction:	? Documentation will be included in the records for resident #2, #5, #6, #7 and #8 based on the initial UAI dates. This documentation will indicate initial interview in lieu of specific admission interview record. ? A documented interview between the Executive Director or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any will be completed for all admissions to the community. ? The document indicating completion of the interview will be maintained in each resident?s administrative file kept in the facility business office. ? The Executive Director or designee will complete weekly audits through 04/30/2024 to ensure compliance. [SIC]
Standard #:	22VAC40-73-325-A
Description:	Based on a review of resident records, the facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating shall be completed, for one of the resident records reviewed. EVIDENCE: 1. Resident #3 was admitted to the facility on 11/27/2023; there was no documentation of a written fall risk rating found in the record for resident #3. 2. Per interview with staff #6, a fall risk rating had not yet been completed for resident #3.
Plan of Correction:	? A fall risk assessment has been completed for resident #3. ? A documented fall risk rating will be completed for all residents admitted to the facility upon the completion of an ISP and will be maintained in the resident?s record. ? The HWD or designee will complete audits of resident records to ensure a fall risk rating is in place. [SIC]
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually for three of the resident records reviewed. EVIDENCE: 1. Resident #5 was admitted to the facility on 02/10/2021; the most recent documentation of an annual review and update of the fall risk rating found in the record for resident #5 was dated 01/01/2023. 2. Resident #7 was admitted to the facility on 12/30/2020; the most recent documentation of an annual review and update of the fall risk rating found in the record for resident #7 was dated 01/01/2023. 3. Resident #8 was admitted to the facility on 06/28/2021; the most recent documentation of an annual review and update of the fall risk rating found in the record for resident #8 was dated 01/01/2023. 4. Per interview with staff #6, more recent fall risk ratings had not yet been completed for residents #5, #7 and #8.
Plan of Correction:	? A fall risk rating has been completed and documented for residents #5, #7 and #8. ? The HWD or designee will complete an updated fall risk rating for all residents annually, when the condition of a resident changes and/or after a fall occurs. ? The HWD or designee will complete routine audits to insure compliance with this requirement. [SIC]
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the protentional resident will have a length of stay greater than three days, for one of the resident records reviewed. EVIDENCE: 1. Resident #4 was admitted to the facility on 02/12/2024 and there was no documentation found in the record indicating the facility ascertained whether the resident is a registered sex offender. 2. Staff #7 was unable to locate documentation that the facility ascertained whether the resident is a registered sex offender.
Plan of Correction:	?The sex offender registry was completed for resident #4 on the date of inspection, 03/01/2024. ? The Business Office Manager will complete a sex offender registry check prior to all future admissions to the facility. A record of these checks will be maintained in a designated binder and kept in the business office. ? The Executive Director will complete weekly audits of sex offender registry binder through 04/30/2024 to ensure compliance. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to include all required information on the comprehensive individualized service plan (ISP) for two of the resident records reviewed. EVIDENCE: 1. Resident #4 was admitted to the facility on 02/12/2024. Per notes observed in the record for resident #4, a home health nurse completed a skilled nursing visit on 02/13/2024, during which an evaluation for speech therapy, physical therapy and occupational therapy occurred. Subsequent notes beginning 02/14/2024 through 02/28/2024 document resident #4 received skilled nursing, physical therapy, occupational therapy and speech therapy services. The ISP completed 02/12/2024 was not updated with a description of the specific home health services provided to resident #4. 2. The most recent ISP for resident #7 was completed on 01/18/2024. Per a physician?s order dated 02/20/2024, home health services were requested for wound care, and a physical therapy evaluation and treatment. Per notes observed in the record for resident #7, a physical therapy evaluation with plan of care established occurred on 02/21/2024 and skilled nursing provided wound care on 02/22/2024 and 02/26/2024. The ISP was not updated with a description of the specific home health services provided to resident #7.
Plan of Correction:	? The ISP for resident #4 has been updated to reflect appropriate home health services. ? The ISP for resident #7 has been updated to reflect appropriate home health services. ? ISPs will be completed within 30 days after admission and shall include the following: description of identified needs and date identified based upon the UAI, admission physical examination, interview with resident, fall risk assessment and other sources of information. ? The HWD or designee will complete weekly audits of current resident ISPs to insure accuracy of the document. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In resident room #322, there was dirt and debris observed on the floor under and round the recliner. There were also crumpled napkins or tissues and a Styrofoam bowl observed under the recliner. 2. In resident room #306, there were particles of dirt and debris observed on the floor throughout the apartment, on the carpeted areas and in the corner of the kitchen to the right of the range. There was significant clutter, including bulk food items, discarded gift bags and tissue paper, cardboard boxes and packing materials throughout the apartment, potentially creating a trip hazard. Above and to the left of the computer desk, there was a crack in the wall extending from the top right corner of the door frame diagonally toward the ceiling, approximately two feet in length. 3. In resident room #205, there were several dark stains observed on the carpeting, in the living area and the area by the entrance/kitchen. There were dark lines on the wall to the right at the entrance to the apartment and on the wall to the left of the entrance to the bedroom, approximately six inches from the floor. 4. In resident room #109, there were two dark stains on the carpet in front of the recliner, approximately six to eight inches in diameter. 5. In resident room #137, there were several dark stains on the carpeting throughout the apartment, including at the entrance by the kitchen, the living area, the area designated as an office and the bedroom in front of the recliner.
Plan of Correction:	? Room 322 has been cleaned, specifically addressing dirt and debris found under and around resident?s recliner. ? Executive Director has met with resident in room 306 to discuss and address concerns with clutter, needed repairs and necessary cleaning. Completion of needs in this apartment to be completed by 03/31/2024. ? Walls in room 205 will be cleaned and/or painted to remove dark marks noted. ? Carpets in apartments 109, 137, 205, 306 313 will be cleaned by 03/31/2024. ? 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]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. The licensing inspector (LI) observed a strong foul odor upon walking into resident room #313. 2. The LI observed a strong foul odor upon walking into resident room #306.
Plan of Correction:	? Executive Director will meet with resident and responsible parties for rooms 306 and 313 to address noted foul odors by 03/31/2024. ? Plan for pet care in each resident?s room will be developed to eliminate foul odors by 03/31/2024. ? Ventilation for 306 and 313 will evaluated to ensure proper air circulation exist. ? Executive Director or designee will conduct random audits of resident apartments to ensure compliance with this requirement. [SIC]