Virginia DSS · Assisted Living Facility

Brookdale Bristol

📍 375 Liberty Place, Bristol, VA, 24201

ID 28936One Year licenseActive
16
Inspections
On record
9
With violations
Visits that cited something
7
Clean visits
Nothing cited
36
Violations cited
Individual findings
25
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Brookdale Bristol was inspected 16 times between March 21, 2021 and March 26, 2026 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 36 violations under 25 distinct standards. 2 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 14 of these 16 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
04/27/2027
Administrator
James Floyd
Licensing inspector
Rebecca Berry
Inspector phone
(276) 608-3514
Approved for
Assisted Living · Non-Ambulatory

Inspection History

16

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

March 26, 2026Inspection10 violations
Inspection dates
03/262026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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: 03/26/2026, 9:50am to 4:38pm 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: 97 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 3 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 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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
22VAC40-73-450-F
Based on a review of resident records, the facility failed to ensure that the updated individualized service plan (ISP) included all required information.
Evidence
  1. The uniform assessment instrument (UAI) for resident #1, dated 05/19/2025, identified the following needs in which the resident requires assistance: Stairclimbing (mechanical & human help, supervision) and mobility (mechanical help only). On the individualized service plan (ISP) for resident #1, dated 05/19/2025, the pre-populated sections addressing stairclimbing and mobility were marked “N/A”.
  2. The record for resident #4 contains the following order, dated 02/15/2025: Oxygen (O2) at 3 liters per minute (LPM) via nasal cannula via concentrator or inogen device/portable oxygen continuous, every shift for congestive heart failure. On the ISP for resident #4, dated 11/18/2025, the section addressing oxygen concentrator/portable includes the following description of services to be provided: Requires use of O2 at 2 LPM via nasal cannula via concentrator or portable device.
Plan of correction
• The UAI for resident #1 has been verified to reflect his need for assistance with stairclimbing and mobility. • The ISP for resident #1 has been updated to indicate his need for assistance with stairclimbing and mobility. • The ISP has been corrected to show resident #4 need for Oxygen (O2) at 3 liters. • To assist with ongoing compliance, the HWD or designee will complete monthly audits of current resident ISPs for three (3) months to verify accuracy. [SIC]
22VAC40-73-520-I
Based on observations made during the tour of the building, the facility failed to have a written schedule of activities that includes the hour of the activity.
Evidence
  1. The activities calendar for March 2026 did not include the time frames or duration of the activities listed. The Licensing Inspector was unable to determine if the correct number of activity hours are being offered by the facility for this reason.
Plan of correction
• The Resident Engagement Coordinator (“REC”) has updated the activities calendar for April 2026 to reflect the beginning and end times for each scheduled program. • The REC was retrained on the activity requirements by the ED or designee. • To assist with ongoing compliance, the ED or designee will complete monthly audits, for three (3) months, of the programing calendars/schedules to verify duration times are in compliance. [SIC]
22VAC40-73-870-C
Based on observations made during the tour of the building, the facility failed to have adequate provision for the collection of garbage and waste material.
Evidence
  1. Outside of room #109 the Licensing Inspector observed a small bag containing trash and an empty soda can box.
  2. Between the exit door and outside of room #137 the Licensing Inspector observed a box with trash sitting in the hall.
  3. Both of these observations were made at approximately 11:04am on the date of the inspection.
Plan of correction
• Trash/garbage items outside of room #109 were removed and disposed appropriately. • Box of trash between exit door and outside of room #137 has been removed and disposed of appropriately. • Residents will be provided guidance, by the ED or designee on appropriate trash/garbage collection and disposal. • The Maintenance Director, ED, or designee will retrain associates on timely trash collection. • ED or designee will complete weekly inspections of community to verify garbage/trash is collected and disposed. [SIC]
22VAC40-73-680-D
Based on observations made during the noon medication pass, review of resident records, and physician orders, the facility failed to administer a medication to one resident in accordance with the physician’s or other prescriber’s orders.
Evidence
  1. During the noon medication pass staff #1 crushed resident #10’s 325mg ferrous sulfate and mixed it in apple sauce and administered it to the resident.
  2. There was no physician’s order to crush, mix in apple sauce, and administer the 325mg ferrous sulfate for Resident #10.
Plan of correction
• An order from the medical provider of resident #10 was obtained to crush all medications and mix with medium of choice, including 325mg ferrous sulfate. • Re-training will be provided to direct clinical staff by the HWD or designee on following prescriber’s instructions for medications and treatments. • The HWD or designee will audit resident medication/treatment orders weekly for three (3) weeks to verify administration instructions are followed by clinical staff. [SIC]
22VAC40-73-750-B
Based on a tour of the building, the facility failed to ensure that bedrooms shall contain all required items.
Evidence
  1. An operable bed lamp or bedside light was not observed in resident room #321.
  2. An operable bed lamp or bedside light was not observed in resident room #315.
Plan of correction
• An operable lamp has been provided to residents in room #315 and #321. • Upon admission, resident rooms will be inspected by the Maintenance Director or designee to verify all items required under regulation are present. • Documentation will be provided for any residents declining the listed items. • To assist with ongoing compliance, the ED or designee will inspect resident rooms weekly for three (3) months to verify required items are present or there is documentation on a resident’s declination of specific items. [SIC]
22VAC40-73-380-A
Based on a review of resident records, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, all required personal and social information on a person shall be obtained.
Evidence
  1. The resident – personal/social data form for resident # 1 did not contain the following information: Local department of social services, if applicable and other agency, if applicable. The section addressing current behavioral and social functioning contained only the word, “None,” and the section addressing problems was left blank.
  2. The resident – personal/social data form for resident #3 did not contain the following information: Interests/hobbies, allergies and responsible individual, if needed.
  3. The resident – personal/social data form for resident #4 did not contain the following information: Interests/hobbies and lifetime vocation, career or primary role.
  4. The resident – personal/social data form for resident #6 did not contain the following information: Current behavioral and social functioning, strengths, and problems.
Plan of correction
• The personal/social data form has been updated to provide missing and additional information for resident #1. • For resident #3, information on hobbies/interests, allergies and responsible individual will be obtained on the personal/social data form. • For resident #4, information on hobbies/interests, lifetime vocation, career or primary role will be obtained on the personal/social data form. • For resident #6, information on current behavioral and social functioning, strengths, and problems will be obtained on the personal/social data form. • The ED or designee will retrain the administrative associates on completing the personal/social data forms completely. • To assist with ongoing compliance, the ED or designee will audit resident files weekly for three (3) months to verify personal/social data forms are accurately completed. [SIC]
22VAC40-73-610-E
Based on observations and interviews with the dining staff, the facility failed to have a copy of a diet manual containing acceptable practices and standards for nutrition readily available to personnel responsible for food preparation.
Evidence
  1. The dietary manager stated she had only been there a week and was not sure where the dietary manual was located.
  2. The Licensing Inspector observed the kitchen area and spoke with two kitchen staff, and a dietary manual was unable to be located.
Plan of correction
• The Diet Manual for the community was located by the Dietary Manager on 03/27/2026. • The Diet Manual was reviewed by the ED and Dietary Manager on 03/27/2026 to verify its contents are current. • The dietary staff will be retrained by the ED or designee on maintaining the Dietary Manual in a consistent location to verify it is available to personnel for food preparation. • The Dietary Manager or designee will audit kitchen area weekly for three (3) months to verify the manual is available. [SIC]
22VAC40-73-320-A
Based on a review of resident records and interview with staff, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician, and the report of such examination shall be on file at the assisted living facility.
Evidence
  1. Resident #1 was admitted to the facility on 05/19/2024.
  2. The record for resident #1 contained an 8-page document which indicates it is the history & physical information for the resident. This document notes the encounter with the physician occurred on 12/13/2023, approx. five months prior to admission.
  3. The Physician/Healthcare Provider Plan of Care document located by staff #4 was signed by the physician on 05/04/2024, but on page 1 it indicates the date of physician visit occurred on 12/13/2023.
Plan of correction
• The Medical records for resident #1 will be reviewed by Health and Wellness Director (HWD) to verify current orders are accurate and up to date. • Direct clinical staff will be retrained by the HWD on clinical admission requirements and documentation. • All clinical documents will be reviewed by the HWD or designee prior to admissions. • To assist with ongoing compliance, the HWD or designee will complete monthly audits for three (3) months to verify resident records contain correct information/documentation. [SIC]
22VAC40-73-210-F
Based on the review of staff records, the facility failed to provide documentation of at least two hours of training focused on infection control on the training log for one staff member.
Evidence
  1. Staff #3 was hired on 10/11/2023.
  2. According to the documentation of her annual training she had only received 1.25 hours of infection control training.
Plan of correction
The following is a summary of the Plan of Correction for Brookdale Bristol. This Plan of Correction Action Report dated March 26, 2026. This correction is not intended 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 #3 completed a one-hour Infection Control course on 04/02/2026 to meet the two-hour requirement. • The community Executive Director (“ED”) or designee has adjusted the training system. • An audit of all staff training records will be completed by the ED or designee to verify compliance with the two-hour training requirement on Infection Control. • To assist with ongoing compliance, the ED or designee will review staff training records quarterly for two (2) quarters. [SIC]
22VAC40-73-870-A
Based on a tour of the building, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. A stain was observed on the carpet near the entrance to resident room #320.
  2. Particles of dirt and debris were observed on the vinyl flooring throughout resident room #328.
  3. A stain was observed on the carpet near the entry to the bedroom in resident room #309.
  4. The hallway carpet on the second and third floors near rooms #215 and #318 respectively has loosened causing buckling that may pose a trip hazard.
  5. Outside the mechanical room on the first floor the surface of the vent cover for the heating/cooling return was found to be noticeably covered in dust.
  6. The carpet outside of the laundry room on the first floor was found to be dirty and observed to be discolored.
Plan of correction
• The carpet stain near the entrance of resident room #320 will be treated/cleaned by the Maintenance Director or designee by 03/31/2026. • Resident room #328 was cleaned on 03/27/2026. All dirt and debris from the flooring was removed. • The carpet stain near the bedroom entry of resident room #309 will be treated/cleaned by the Maintenance Director (“MD”) or designee by 03/31/2026. • The hallway carpet on the second and third floors near room #215 and #318 will be repaired by the MD or designee to remove any potential risk of a trip hazard. • The vent cover for the heating/cooling return for the first floor mechanical room has been cleaned to remove any noticeable dust. • The carpet outside of the first floor laundry room will be treated/cleaned by the MD or designee by 03/31/2026. • Associates will be re-trained by the Maintenance Director or designee on floor care, which will include cleaning methods and reporting repair needs. • To assist with ongoing compliance, the Maintenance Director or designee will conduct weekly audits of common area flooring with focus on transition locations for three (3) months. [SIC]
March 10, 2026Complaint survey1 violation
Inspection dates
03/10/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/10/2026, 12:43pm to 2:57pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/11/2026 regarding allegations in the area(s) of: Staffing and supervision, resident care and related services, building and grounds. Number of residents present at the facility at the beginning of the inspection: Not obtained The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Building and grounds A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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
22VAC40-73-870-A
Based on observations made during a tour of the building, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. Six small to medium sized stains were observed on the hallway carpeting between resident rooms #101 and #108.
  2. In resident room #101, the cream color flooring in the bathroom appeared soiled/discolored.
  3. In the bathroom for resident room #101, a large discolored area was observed on the ceiling above the shower, and a smaller discolored area was observed on the ceiling by the vent fan. The areas appeared to be caused by a water leak.
  4. Several smudges were observed on both sets of double sliding doors at the main entrance to the building.
Plan of correction
The following is a summary of the Plan of Correction for Brookdale Bristol. This Plan of Correction Action Report dated April 16, 2026. This correction is not intended 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. 870-A (A-2) • The carpet stains on the hallway carpeting between #101 and #108 have been treated/cleaned by the Maintenance Director or designee by 03/31/2026. • The bathroom flooring in apartment #101 was replaced on 03/20/2026 by an outside contractor. • The bathroom ceiling of apartment #101 repaired by an outside contractor on 04/14/2026 removing all the noted discoloration/stains. • The smudges observed on both sets of double sliding doors at the main entrance have been cleaned/removed. Staff have been assigned to monitor/clean front entrance doors daily and appropriately address cleaning needs. • Associates will be re-trained by the Maintenance Director or designee on floor care, which will include cleaning methods and reporting repair needs. • To assist with ongoing compliance, the Maintenance Director or designee will conduct weekly audits of common area flooring with focus on transition locations for three (3) months. • Completion date: 05/31/2026 [SIC]
April 28, 2025Inspection0 violations
Inspection dates
04/28/2025
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: 04/28/2025, 11:36am to 12:28pm 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 04/14/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 89 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 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 no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 28, 2025Inspection0 violations
Inspection dates
04/28/2025
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: 04/28/2025, 11:00am to 11:35am 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: 89 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 2 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 no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 12, 2025Inspection6 violations
Inspection dates
03/12/2025, 03/13/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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: 03/12/2025, 9:48am to 4:02pm and 03/13/2025, 9:52am to 1:55pm. 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: 91 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: 3 Number of interviews conducted with residents: 2 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
22VAC40-73-450-C
Based on a review of resident records, the facility failed to ensure all required information is included on the comprehensive individualized service plan (ISP).
Evidence
  1. The facility routinely includes oxygen therapy as part of the ISP, with the description of needs as OXYGEN CONCENTRATOR/PORTABLE. The order summary report signed on 12/27/2024 for resident #2, includes an order for Continuous Oxygen at 3LPM via nasal cannula. The ISP dated 08/08/2024 for resident #2 was marked N/A in the section addressing oxygen therapy.
  2. Resident #4 is currently receiving hospice services. Hospice is identified on the ISP dated 04/10/2024 for resident #4; however, the following information was not provided: Description of services to be provided, when and where services will be provided, and expected outcomes and date of expected outcomes.
Plan of correction
• The ISP for resident #2 has been updated to include a description of the resident’s need as “Oxygen Concentrator and Portable Inogen”. • The ISP for resident #4 has been updated to include description of services to be provided, when and where services will be provided, and expected outcomes and date of expected outcomes. [SIC] • The HWD or designee will complete bi-weekly audits of current resident ISPs to maintain accuracy of the documents.
22VAC40-73-610-D
Based on a review of resident records and interview with staff, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician's or other prescriber's orders.
Evidence
  1. The Physician/Healthcare Provider Plan of Care for resident #2 includes an order dated 03/06/2025 for a Liberalized Renal Diet, with the following description: The Liberalized Renal Diet limits sodium, potassium and phosphorous with adequate calories and protein. Staff #22 stated a low sodium diet is provided for most residents, but confirmed the dietary order was not available in the kitchen and was not being followed at the time of inspection.
  2. The Physician/Healthcare Provider Plan of Care for resident #4 includes an order dated 04/09/2024 for a Texture Modified Diet, with the following description: The Textured Modified Diet is the Regular Diet, modified to meet texture modified standards. It offers food that is moist and soft-solid. All meats and poultry are ground with the exception of small tender pieces of meat allowed in soups. It is expected that mixed textures are tolerated on this diet. Staff #22 indicated resident #4 may have been “released” from the diet, however, an order to discontinue the diet was not observed in the record for resident #4. Staff #22 stated meats were being cut up for the resident, but confirmed the dietary order was not available in the kitchen and was not being followed at the time of inspection.
Plan of correction
• The diet order for resident #2 has been reviewed by Health and Wellness Director and the Dining Services Coordinator. Resident #2 has been confirmed to receive a Liberalized Renal diet with limited sodium, potassium and phosphorus with adequate calories and protein. • The diet order for resident #4 has been reviewed by the Health and Wellness Director and Dining Services Coordinator. Resident #4 has been confirmed to receive a Textured Modified diet, which will be a regular diet modified to meet texture modified standards. The food will be moist and soft-solid. The meats and poultry will be ground with the exception of small tender pieces of meats allowed in soups. • A binder has been prepared with current diets orders described for each resident. Clinical and Dining Services staff will meet bi-weekly to review residents’ diets and any needed changes, • The HWD or designee will audit diet orders monthly to verify accuracy. [SIC]
22VAC40-73-920-C
Based on a tour of the building, the facility failed to ensure there shall be ventilation to the outside in order to eliminate foul odors.
Evidence
  1. In resident room #131, the exhaust fan in the bathroom did not appear to be working as it made no sound when switched on.
Plan of correction
• The exhaust fan of apartment #131 has been repaired and is now working properly. • Bathroom exhaust fans will be included on Preventive Maintenance inspections conducted monthly. • Maintenance Director or designee will audit all apartments to maintain that bathroom exhaust fans are working properly. [SIC]
22VAC40-73-380-A
Based on a review of resident records, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, all required personal and social information on a person shall be obtained.
Evidence
  1. The record for resident #2 did not contain the following personal/social data: Interest/hobbies, lifetime vocation, career or primary role, current behavioral and social functioning, strengths, and problems.
  2. The record for resident #1 did not contain the following personal/social data: Interests/hobbies, lifetime vocation, career or primary role, clergyman/place of worship, if applicable, current behavioral and social functioning (marked N/A on Resident – Personal/Social data form), strengths (marked N/A on Resident – Personal/Social data form), and problems (marked N/A on Resident – Personal/Social data form).
  3. The record for resident #3 did not contain the following personal/social data: Current behavioral and social functioning, strengths, and problems.
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, 2025. 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. • The Personal/Social Data form for resident number #2 has been updated with information for Interest/hobbies, lifetime vocation, career or primary role, current behavioral and social functioning, strengths, and problems. • The Personal/Social Data form for resident number #1 has been updated with information for Interest/hobbies, lifetime vocation, career or primary role, current behavioral and social functioning, strengths, and problems. • The Personal/Social data form for resident #3 has been updated and now includes information for their current behavioral and social functioning, strengths, and problems. • The ED or designee will complete bi-weekly audits of resident records to maintain completion of information. [SIC]
22VAC40-73-700-1
Based on a review of resident records, the facility failed to ensure that when oxygen therapy is provided, physician's or other prescriber's order contain all required information.
Evidence
  1. The record for resident #2 contains an order for oxygen stated as follows: Continuous oxygen at 3 LPM via nasal cannula every shift for sob. The order does not contain the oxygen source, such as compressed gas or concentrators.
  2. The record for resident #9 contains an order for oxygen stated as follows: O2 at 2LPM via nasal cannula per delivery device of resident’s choice PRN at bedtime every day and night shift for shortness of breath check for placement while in use.
Plan of correction
• The oxygen order for resident #2 has been corrected and now includes a description of the source as concentrator, portable tank and/or inogen. • The oxygen order for resident #9 has been corrected and no longer states “resident’s choice” as the O2 source, but instead states “concentrator and/or portable tank” as the O2 source. • The HWD or designee will audit O2 orders for residents receiving O2, bi-weekly to maintain oxygen therapy orders contain all required information. [SIC]
22VAC40-73-870-A
Based on a tour of the building, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. A stain was observed on the carpet in room #328 just past the entrance on the right, near the kitchen.
  2. Several stains were observed on the carpet in room #218, including two stains red and orange in color near the foot of the bed, and smaller dark stains also near the bed.
  3. Several small dark stains were observed on the carpet in room #205, throughout the main living area.
Plan of correction
• Carpet stain identified in apartment #328 has been treated and cleaned. • All carpet in apartment #218 has been treated and cleaned with specific attention given to noted stains. • All carpet in apartment #205 has been treated and cleaned with specific attention given to noted stains. • Associates will be provided in-service on floor care, which will include appropriate cleaning methods for carpeting and other flooring. [SIC]
April 26, 2024Inspection0 violations
Inspection dates
04/26/2024
Areas reviewed
22VAC40-73 PERSONNEL
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: 04/26/2024, 12:11pm to 12:49pm 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: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: 1 Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 1 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 no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 29, 2024Inspection9 violations
Inspection dates
02/29/2024, 03/01/202465
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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
22VAC40-73-870-B
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]
22VAC40-73-870-A
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]
22VAC40-73-350-B
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]
22VAC40-73-450-C
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]
22VAC40-73-325-B
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]
22VAC40-73-260-A
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]
22VAC40-73-310-B
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]
22VAC40-73-210-D
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]
22VAC40-73-325-A
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]
November 15, 2023Inspection2 violations
Inspection dates
11/15/2023, 12/19/2023
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: 11/15/2023, 11:30am to 12:29pm and 12/19/2023, 4:01pm to 4:06pm 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 09/19/2023 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: N/A 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
22VAC40-73-680-D
Based on a review of facility records and interviews with staff, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The Licensing Inspector (LI) received a facility self-report on 09/21/2023 stating resident #1 was prescribed morphine concentrate beginning 09/13/2023 and multiple nurses administered more morphine than prescribed to resident #1.
  2. The original physician’s verbal order dated 09/13/2023 was documented as follows: Start morphine concentrate 100mg/5ml (20mg/ml), take 0.5ml SL q one hour prn (as needed) for pain or shortness of breath. The order was signed on 09/14/2023 and stated, “please dispense individual syringes.”
  3. A verbal order given on 09/16/2023 was documented as follows: D/C previous morphine orders. Morphine scheduled 0.5ml (10mg) – take 2 prefilled syringes (20mg) every 4 hours. Increase prn 0.5ml from every hour as needed to 20mg (1ml) every 15 min as needed (2 prefilled syringes). Morphine to be given SL. The signed order was provided to the facility 09/26/2023.
  4. Per interview with staff #1, prefilled “half” syringes with 10mg morphine were being used to administer the medication as ordered in item number two (above). Staff #1 reported when the new order changed the dose to 20mg, two syringes prefilled with 10mg of morphine were being given, until the supply ran out. Staff #1 reported after all the prefilled syringes were used, the pharmacy sent a bottle of the prescribed morphine to the facility.
  5. Per interview with staff #2, resident #1 was receiving two 0.5mL prefilled syringes of morphine as ordered in item number three (above) until the supply on hand ran out. Staff #2 reported the supply was depleted during night shift and the pharmacy sent a bottle of the prescribed morphine to the facility. Staff #2 reported night shift staff notified oncoming day shift staff that two syringes of morphine were being given to resident #1, and staff were drawing up the morphine out of the bottle provided by the pharmacy.
  6. According to the individual narcotic log: a. The final dose of two prefilled 0.5mL syringes was given on 09/17/2023 at 7:10pm. b. On 09/18/2023, 1mL of morphine (20mg/mL) was given at the following times: 4:15am, 4:30am, 4:45am, 5:00am, 6:00am. c. On 09/18/2023, 2mL of morphine (20mg/mL) was given at the following times: 7:19am, 8:37am, 9:19am, 10:20am, 11:15am, 11:40am, 12:05pm, 12:20pm, 12:40pm, 1:00pm, 1:15pm, 1:30pm, 2:10pm, 3:00pm, 3:30pm.
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 December 19, 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. Staff #1 and #2 were counseled and provided a written corrective action notice on 09/20/2023. Additional training will be provided to staff #1 and #2 regarding medication administration guidelines with specific focus on narcotics no later than 01/31/2024. Random audits/monitoring will be conducted by the Health 01/31/2024. [SIC]
22VAC40-73-680-B
Based on review of facility records and interview 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 a note documented on the individual narcotic log on 09/18/2023, a multidose bottle of morphine was converted to prefilled syringes by hospice.
  2. Per interview with staff #3, a hospice employee did convert the multidose bottle of morphine to prefilled syringes on 09/18/2023.
Plan of correction
Not published by VDSS.
November 15, 2023Inspection0 violations
Inspection dates
11/15/2023
Areas reviewed
22VAC40-61 PERSONNEL
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: 11/15/2023, 11:06am to 11:27am 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: 0 Number of interviews conducted with residents: N/A 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 no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 2, 2023Inspection1 violation
Inspection dates
08/02/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 08/02/2023, 2:12pm to 3:35pm 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 06/07/2023 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: 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: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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
22VAC40-73-680-D
Based on facility self-report and a review of resident and facility records, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Per the physician’s order dated 06/01/2023, resident #1 was prescribed Lorazepam (Ativan) 0.5mg tablet, take 4 tablets (2mg total) by mouth every 12 (twelve) hours for 14 days.
  2. Per the June 2023 Medication Administration Record (MAR) for resident #1, the instructions state Ativan Oral Tablet 0.5 mg (Lorazepam), give 4 tablets by mouth two times a day for anxiety/squamous cell carcinoma of the lung for 14 days.
  3. Per facility self-report, resident #1 was prescribed Lorazepam 2mg to be administered at 8pm. The medication was packaged as 4 - 0.5mg tablets in each dose. Staff #1 misunderstood the order and administered four doses (8mg total) in error on 06/05/2023, 7:04pm.
  4. Per facility documentation and interviews with staff #2 and staff #3, staff #3 discovered the error on 06/06/2023. The situation was addressed with staff #1, who did admit to the error.
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 August 02, 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. • Staff #1 who made the error was counseled and provided a written corrective action notice on 06/07/2023. • Additional training will be provided to staff #1 regarding medication administration guidelines with specific focus on narcotics no later than 08/31/2023. • Random audits/monitoring will be conducted by the Health and Wellness Coordinator/designee for three months to verify compliance with the community’s medication administration guidelines. [SIC]
April 11, 2023Inspection1 violation
Inspection dates
04/11/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
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: 04/11/2023, 1:47pm to 3:02pm 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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
22VAC40-73-870-A
Based on observations made during a tour of the facility, the facility failed to keep all interior areas of the building in good repair and clean. 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 brown stain on the carpet, covering an area of approximately eight to 10 inches. 3. On the second floor on hallway A-2 outside the medication room, the transition strip from the laminate flooring to the carpet had a piece of carpet that was raised, approximately 18 inches long; this could present a trip hazard.
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 April 11, 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. • The flooring/transition strip concerns stated in items 1 and 3 have been addressed/repaired by the facility maintenance staff on 04/12/23. The stain described in item 2 and been addressed by commercial carpet cleaning contractor, as well as by community staff. Stain has improved and will continue to be treated on weekly schedule until no longer noticeable. Commercial carpet cleaning service has been set up and scheduled for a quarterly service. • Associates have been 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]
February 22, 2023Inspection5 violations
Inspection dates
02/22/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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
22VAC40-73-450-C
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]
22VAC40-73-870-A
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]
22VAC40-73-440-D
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]
22VAC40-73-450-H
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]
22VAC40-73-100-C-2
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]
February 17, 2022Inspection0 violations
Inspection dates
02/17/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
Two licensing inspectors conducted an unannounced mandated license renewal inspection at Brookdale Bristol on 02/17/2022. The inspection started at 10:15 am and concluded at 2:20 pm. A sample of resident files were reviewed. Required posting's were checked. 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 with the administrator and other key staff on 02/17/2022 and at that time an opportunity was given to find items that were not available in files. As a result of this no violations are being cited. If you have any questions or concerns please contact your inspector at 276-608-3514. Thank you for your cooperation and assistance.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 3, 2021Complaint survey0 violations
Inspection dates
11/03/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 11/03/2021. Interviews were conducted with residents and the physical plant was observed relating to the allegations of issues with cleanliness and resident care. The information gathered did not support the allegations in the complaint and therefore was determined to be not valid. If you have any questions or need assistance, contact your licensing inspector at (276) 608-3514. Arrived: 12:10 PM and Exit: 1:20 PM
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 31, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 03/21/2021 and concluded on 04/02/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 57. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules for the past two weeks, the most recent health and dietitian oversight reports for the past year, the most recent fire and health inspection reports, and the fire and emergency drills for the past year submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 21, 2021Inspection1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 03/21/2021 and concluded on 03/24/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The Director of Nursing was contacted by telephone to conduct the investigation. The licensing inspector emailed the Director of Nursing a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-680-D
Based on interviews with staff and documentation review, the facility failed to ensure medications were administered in accordance with physician's or other prescribers instructions and consistent with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident # 1 was admitted to the facility on 02/27/2014.
  2. According to documentation submitted by the facility as part of a self-reported incident, resident # 1 is prescribed Carboxymethylcellulose Sod PF Solution 0.5% to instill one drop in both eyes four times a day for dry eyes.
  3. On the evening of March 21, 2021 at approximately 8:30 pm, staff # 1 went into resident #1's room to administer her fourth dose of the prescribed eye drops. According to documentation and an interview with the Director of Nursing staff # 1 placed the medication on the resident's nightstand to assist the resident with personal care needs. Staff # 1 retrieved what she thought was the resident's prescribed eye drops and without paying attention instilled one drop of artificial nail glue into resident #1's left eye. Resident # 1 immediately complained of a burning sensation and staff # 1 realized she had used the artificial nail glue instead of the resident's eye drops. Staff # 1 immediately flushed resident # 1's eye and notified 911 for transport to the ER.
  4. On March 22, 2021 resident # 1's eye was still glued shut. Resident # 1 was referred to an eye specialist and the appointment took place at 2 pm on this date. Resident # 1 was prescribed an antibiotic and artificial tears to be placed in resident # 1's left eye three times a day for 10 days. A protective lens was also placed in resident # 1's eye and she will continue to follow up with the eye specialist to ensure there are no long term effects.
Plan of correction
1. Follow-up visits with medical personnel scheduled for resident to monitor and prevent potential negative effect. 2. On 3/22/2021, Follow-up discussion was held with staff # 1 and additional information was gathered regarding the occurrence. Staff # 1 was notified of her suspension pending an investigation into the matter. 3. Based on outcome of incident investigation, decision was made terminate staff members employment effective 03/24/2021. 4. Retraining will be conducted for licensed and registered staff completed by the HWD/designee regarding the community's mediation administration guidelines no later than 04/03/2021. 5. Random audits/monitoring will be conducted by the Health and Wellness Director/designee for three months to verify compliance with the community's medication administration guidelines. [sic]