Memory Care at Bristol — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Memory Care at Bristol was inspected 16 times between April 18, 2022 and October 21, 2025 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 29 violations under 27 distinct standards. 1 inspection was 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

11/30/2027

Administrator

Cirena West

Licensing inspector

Rebecca Berry

Inspector phone

(276) 608-3514

Approved for

Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

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

October 21, 2025Inspection3 violations

Inspection dates

10/21/2025

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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 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: 10/21/2025, 10:22am to 3:56pm 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 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

22VAC40-73-750-B

Based on a tour of the building, the facility failed to ensure bedrooms shall contain all required items.

Evidence

There was no operable bed lamp or bedside light observed in room #321.
There was no operable bed lamp or bedside light observed in room #312, for the bed by the window.
There was no operable bed lamp or bedside light observed in room #311.

Plan of correction

1.) Written request for not wishing to have bed lamp or bedside light for room #311, 312, and 321 has been received from POA/responsible party. Memory Care Director has created room inventory form with listed items required per 22VAC40-73-750 to be included in new admission packet. The form has area for POA/responsible party to sign for any items they wish not to have in the resident’s room. 2.) All current residents’ rooms have the potential to be affected by the deficient practice. 3.) All current resident rooms were audited to ensure that all required items per 22VAC40-73-750 were present. 4.) There is a potential for the same practice to happen for all new admissions due to deficient practice. 5.) Memory Care Director will conduct audit for all new admissions with the room inventory form created with listed items required per 22VAC40-73-750 and will have POA/responsible party sign for any items that they do not wish to have in the resident’s room going forward. [SIC]

22VAC40-73-680-C

Based on a review of resident records and observations of the medication pass, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule.

Evidence

According to the order dated 10/21/2025 and the October 2025 medication administration record (MAR), resident #4 was to receive the following medication at 9am: Lasix oral tablet 20mg (furosemide), Give 1 tablet by mouth in the morning for edema to bilateral extremities. At the time of the medication pass, this medication was observed by the LI to be administered to resident #4 at approximately 10:38am by staff #1.
According to the Medication Review Report dated 10/21/2025 and the October 2025 MAR for resident #5, resident #5 was to be administered the following medications during the morning medication pass: a. Aspirin 81 oral tablet chewable, Give 1 tablet by mouth one time a day for heart health (8am) b. Glipizide oral tablet 5mg, Give 1 tablet by mouth two times a day for DM (9am) c. Lorazepam oral tablet 0.5mg, Give 1 tablet by mouth two times a day for anxiety (8am) d. Metformin HCL oral tablet 500mg, Give 1 tablet by mouth two times a day for DM (9am) e. Metoprolol tartrate oral tablet 25mg, Give 1 tablet by mouth two times a day for HTN (9am) f. Norvasc oral tablet 10mg, Give 1 tablet by mouth one time a day for HTN (8am) g. Seroquel oral tablet 25mg, Give 1 tablet by mouth two times a day for behavioral issues r/t dementia (9am) h. Zestril oral tablet 40mg, Give 1 tablet by mouth one time a day for HTN (8 am)
At the time of the medication pass, the medications noted above for resident #5 were observed by the LI to be administered at approximately 10:43am by staff #1.

Plan of correction

1.) Inservice/education has been provided to staff #1 per facility policy on medication administration paying close attention to times administered as ordered by dosing schedule. Education also included Assisted Living regulations per 22VAC40-73-680 C. Medications shall be administered not earlier than one hour before and not hour later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. 2.) Inservice/education has been provided to all nursing staff/RMA per facility policy on medication administration paying close attention to time administered as ordered by dosing schedule. Education also included Assisted Living regulations per 22VAC40-73-680 C. Medications shall be administered not earlier than one hour before and not hour later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. 3.) All residents have the potential to be affected by the deficient practice. 4.) Memory Care Director will conduct random audits of med passes to ensure regulations are being followed per facility policies and 22VAC40-73-680 C. [SIC]

22VAC40-73-1090-A

Based on a review of resident records, the facility failed to ensure the assessment of serious cognitive impairment includes all required information for one resident.

Evidence

The assessment of serious cognitive impairment for resident #1, dated 06/25/2025, did not include information in the following areas: Thought and perception (e.g., process and content), behavior/psychomotor, and speech/language. These areas on the form used were left blank.
The area of cognitive functions on the assessment of serious cognitive impairment for resident #1 included only the following: A & O x 4 (alert and oriented times four). Areas such as comprehension, problem-solving, attention and concentration, memory, intelligence, abstract reasoning, judgment, and insight were not addressed.

Plan of correction

1.) Although the assessment of serious cognitive impairment of resident #1 cannot be corrected, the facility will ensure going forward that the required information on the assessment is present on all new admissions. Memory Care director will provide instructions with the forms to fill out each area and leave no area blank. 2.) All current resident files have the potential to be affected by the deficient practice. 3.) There is a potential for the same practice to happen for all new admissions due to deficient practice. 4.) The Memory Care Director will conduct audit on receipt of new assessment of serious cognitive impairment from providers to ensure that all required information is present for new admissions. [SIC]

November 18, 2024Inspection0 violations

Inspection dates

11/18/2024

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 11/18/2024, 11:56am to 12:13pm 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: 18 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: n/a 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.

October 8, 2024Inspection3 violations

Inspection dates

10/08/2024

Areas reviewed

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: 10/08/2024, 10:12am to 3:55pm 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: 18 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: 6 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 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

Particles of dirt and debris were observed under the wall hvac unit in resident room #304.
Particles of of dirt and debris, possibly food crumbs, were observed on the floor between the bed and the wall hvac unit in resident room #312.

Plan of correction

1.) Room #304 and #312 had a deep clean done on 10/30/2024. 2.) There is a potential for the same practice to happen in all resident rooms due to deficient practice. 3.) The Director of Environmental Services is retraining all staff on the 5 and 7 step room cleaning process. 4.) The Director of Environmental Services will do 2-3 audits weekly to track progress on staff cleaning with the 5 and 7 step process on the Memory Care Unit. [SIC]

22VAC40-73-1070-B

Based on observations made during a tour of the building, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.

Evidence

Resident #4 was admitted to the safe, secure unit on 01/27/2024. In the bathroom for resident #4, room 315, the following items were observed: A small can of shaving cream with the warning, keep out of reach of children; a bottle of DermaVera Skin & Hair Cleanser with the warnings, for external use only and keep out of reach of children; a bottle of Sparklefresh Mouthwash with the warning, keep out of reach of children.
Resident #5 was admitted to the safe, secure unit on 01/19/2021. In the room for resident #5, the following items were observed: A bottle of Remedy Essentials Cleanse Spray Cleanser with the warning, for external use only; a bottle of UltraSure Anti-Perspirant & Deodorant with the warnings, for external use only and keep out of reach of children; a bottle of Hibiclens Antispetic/Antimicrobial Skin Cleanser with the warning, keep out of reach of children. In the bathroom for resident #5, the following item was observed: A bottle of DermaVera Skin & Hair Cleanser with the warnings, for external use only and keep out of reach of children.
Resident #6 was admitted to the safe, secure unit on 02/01/2023. In the room for resident #6, the following items were observed on an end table: A bottle of Caldesene Medicated Protecting Powder with the warnings, for external use only and keep out of reach of children; a bottle of PeriFresh Rinse-Free Perineal Cleanser with the warning, keep out of reach of children. In the bathroom for resident #6, room 307, the following items were observed: A bottle of Head & Shoulders Dry Scalp Care 2in1 with the warnings, for external use only and keep this and all drugs out of reach of children; a bottle of Selsun Blue with the warnings, for external use only and keep out of reach of children; a can of Dove Men Dry Spray Antiperspirant with the warning, keep out of reach of children.
Resident #7 was admitted to the safe, secure unit on 01/01/2024. In the bathroom for resident #7, room 309, the following items were observed: A bottle of DermaVera Skin & Hair Cleanser with the warnings, for external use only and keep out of reach of children; a bottle of Old Spice Classic After Shave with the warning, keep out of reach of children; a small can of shaving cream with the warning, keep out of reach of children.
Resident #8 was admitted to the safe, secure unit on 06/01/2020. In the bathroom for resident #8, room 311, the following items were observed: A bottle of DermaVera Skin & Hair Cleanser with the warnings, for external use only and keep out of reach of children; a bottle of Remedy Essentials Cleanse Spray Cleanser with the warning, for external use only; a bottle of Old Spice Classic After Shave with the warning, keep out of reach of children.
Room #317 was found to be unlocked during the inspection and contained an unplugged staple gun on the floor between a chair and the bed and a pair of scissors and a box cutter on top of the bed. No residents were living in the room at the time of inspection. Per staff #7, the room was being used for maintenance activities.

Plan of correction

1.) All ordinary materials or objects with indications that may be harmful to a resident have been removed from resident #4, #5, #6, #7, #8’s room and placed in a secured locked room under staff supervision. 2.) The staple gun, pair of scissors and box cutter were removed from room #317 and placed back in the maintenance office with a locked door under staff supervision. 3.) There is a potential for the same practice to happen in all resident rooms and unoccupied rooms due to deficient practice. 4.) All ordinary materials or objects with indications that may be harmful to a resident have been removed from all resident’s rooms and placed in a secure locked room under staff supervision. 5.) Daily room audits are being conducted by each shift to ensure all ordinary materials and objects with indications that may be harmful to a resident are not present in any occupied and non-occupied rooms. Staff will continue audits for two months or until it is a practice for no harmful materials or objects to be found in any occupied or non-occupied room. 4.) The Memory Care Director will conduct random audits to ensure that no harmful materials or objects are found in any occupied or non-occupied room. [SIC]

22VAC40-73-380-B

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

The Resident – Personal/Social Data form for resident #1 was missing a description of the resident’s current behavioral and social functioning on page two. Only one word was used to describe the resident’s current behavioral and social functioning: “wanders.” Further, the strengths and problems sections on page two were blank.

Plan of correction

1.) Resident #1’s current behavioral and social functioning, strengths, and problems have been identified and listed on their Personal/Social Data form. 2.) All current resident files have the potential to be affected by the deficient practice. 3.) All current resident files will be audited to ensure that the resident’s current behavioral and social functioning, strengths and problems are identified and listed on their Personal/Social Data form. 4.) There is a potential for the same practice to happen for all new admissions due to deficient practice 4.) The Memory Care Director will conduct audits to ensure that all behavioral and social functioning, strengths, and problems will be identified and listed on the Personal/Social Data form of all new admissions. [SIC]

April 4, 2024Inspection0 violations

Inspection dates

04/04/2024

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: 04/04/2024, 2:09pm to 2:22pm 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: 19 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: 3 Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: Reviewed documentation of individualized education for staff, in-service, and audits. 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 4, 2024Inspection0 violations

Inspection dates

04/04/2024

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: 04/04/2024, 1:38pm to 1:56pm 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: 19 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: n/a Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: Reviewed documentation of in-service education 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.

January 9, 2024Inspection1 violation

Inspection dates

01/09/2024, 02/13/2024, 02/28/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/09/2024 11:25am to 11:37am, 02/13/2024 10:38am to 10:53am, 02/28/2024 3:45pm to 3:49pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/05/2024 regarding allegations in the area(s) of: Resident care and related services, medication administration Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

22VAC40-73-680-B

Based on facility self-report and interviews with staff, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

Evidence

Per the facility self-report received 01/05/2024, staff #1 reported to staff #4 on 01/04/2024 that staff #2 had pre-pulled 9PM medications before shift change the previous night and on other occasions. Staff #4 contacted staff #3 and she also reported staff #2 had pre-pulled her 9PM medications, for approximately one month.
Per telephone interview with staff #3 on 01/16/2024, staff #2 was pre-pulling the 9PM medications, beginning in early December 2023. She reports staff #2 was removing the medication from the roll packs and narcotic cards and leaving the medications in medicine cups in the locked medication cart in the designated space for each resident.
Staff #2 confirmed in an interview on 02/13/2024 she had pre-pulled medications for the night shift coworkers for the month of December 2023, through January 3, 2024. She reported she removed all medications from the packaging, including narcotics, and left in medicine cups in the designated spaces for each resident in the locked medication cart.
Per written statement provided by staff #1 on 02/26/2024 and interview with staff #1 on 02/28/2024, staff #2 pre-pulled her shift’s medications on three occasions. She reported staff #2 would leave the medications in the cart, in the appropriate slot, to be administered by staff #1.

Plan of correction

1.) Staff #1, #2, and #3 received individualized education regarding the incident with corrective action. 2.) All Memory Care licensed practical nurses and the registered medication aide received in-service on medication administration per facility policies and practices. 3.) All Memory Care medication administration staff received a copy of the administration of medication policies and procedures for future reference and verbalized/demonstrated their knowledge of location of the policies and procedures manual location in the facility. 4.) All Memory Care med cart staff were monitored through a complete med pass to demonstrate their knowledge and compliance to policies and procedures regarding medication administration. 5.) Random audits of med passes have been completed since occurrence and will continue for 3 months. 6.) Memory Care Director has audited the med cart to ensure there are no pre-pulled medications placed in the cart. These random audits will continue for 3 months. [SIC]

November 21, 2023Inspection0 violations

Inspection dates

11/21/2023

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: 11/21/2023, 12:26pm to 12:53pm 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: 18 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: N/A 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.

November 1, 2023Inspection1 violation

Inspection dates

11/01/2023, 11/21/2023, 01/09/2024, 02/09/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 11/01/2023 4:35pm to 5:05pm, 11/21/2023 12:54pm to 1:03pm, 01/09/2024 10:45am to 11:24am, and 02/09/2024 11:47am to 11:53am. 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 10/30/2023 regarding allegations in the area(s) of: Resident care and related services, general supervision and care. Number of residents present at the facility at the beginning of the inspection: 18 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: 0 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 investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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. 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

22VAC40-73-460-D

Based on staff and collateral interviews, the facility failed to provide attention to specialized needs such as wandering from the premises.

Evidence

Resident #1 was admitted to the safe secure unit on 10/27/2023 due to information on the physical examination dated 10/12/2023 which states that she is non-ambulatory, and a physician’s statement dated 10/26/2023 that says resident #1 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger.
The licensing inspector (LI) received an incident report from staff #1 on 10/30/2023 stating resident #1 was found outside the facility the same date. Staff #1 reported she was notified regarding the incident at approximately 9:30am and by that time, resident #1 was back inside the facility. Staff #1 estimated resident #1 exited the safe secure unit unaccompanied at approximately 9:20am.
The individualized service plan (ISP) for resident #1, dated 10/27/2023, includes the description of the need for assistance with mobility, human supervision. In the section entitled “Services to be Provided,” the ISP states “Resident will always be supervised when resident leaves the Memory Care Unit.” The section entitled “Expected Outcomes and Time Frames” states “Resident will be continuously supervised when off Memory Care Unit through 10/27/2024.”
When facing the building, the assisted living facility/safe secure unit is on the right side, and a skilled nursing facility occupies the left side. The two facilities are connected by a common lobby area in the middle.
Per the report, collateral #1 observed resident #1 outside the facility on 10/30/2023 and came over to the safe secure unit to notify the charge nurse. Collateral #1 reported to the LI during an interview on 11/01/2023 that she observed resident #1 on the sidewalk in front of the building through a window on the skilled nursing side of the building.
Staff #2 reported to LI during phone interview on 11/14/2023 she observed resident #1 outside on the sidewalk in front of the building, after being notified that resident #1 was outside the facility.
Staff #3 reported to LI during a phone interview on 11/14/2023 that she went outside after being notified that resident #1 was outside the facility, and observed resident #1 exiting the hotel located across from the facility. Staff #3 reported resident #1 came out one of the front doors of the hotel, to the left of the main entrance. Staff #3 stated she administered morning medications to resident #1 during breakfast in the dining area, at approximately 8:40am.
The hotel and the facility face one another, and each building has a parking lot in front. The parking lots of the two buildings are separated by a grassy median.
Per staff #1, it was determined that an outside service provider had let resident #1 out of the safe secure unit as she was coming in. The facility sign-in sheet indicates the outside service provider entered the building at 9:18am. Staff #1 reported the outside service provider entered the building, dropped off supplies on the skilled nursing side and came over to the safe secure unit briefly to ask a question.
Per accuweather.com, the high temperature outside on 10/30/2023 was 67 degrees Fahrenheit and the low temperature was 44 degrees Fahrenheit. Per wunderground.com, the temperature at 8:53am on 10/30/2023 was 44 degrees Fahrenheit and at 9:53am the temperature was 50 degrees Fahrenheit. Per staff #1, resident #1 was fully dressed while she was outside, including shoes and a cardigan. Staff #1 estimated that resident #1 was outside for no more than 10 minutes.

Plan of correction

1.) Memory Care unit entrance door code was changed immediately and was made a practice that only in house employees will have the code from now on. 2.) Inservice education was provided to all Memory Care staff regarding wandering and elopement and missing persons. 3.) Elopement binder at reception desk was updated to include resident #1 photo and wandering risk assessment. 4.)Resident #1 Uniform Assessment Instrument and Individual Service Plan was updated on 10/30/23 to include behavior patterns of “wandering/Passive-Weekly or more with exit seeking behaviors”. 5.) Signage was placed at entrance to Memory Care for those entering to be on alert for residents and procedure for entrance if needed. [SIC]

October 3, 2023Inspection4 violations

Inspection dates

10/03/2023, 11/01/2023

Areas reviewed

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: 10/03/2023 10:08am to 3:10pm and 11/01/2023 9:08am to 4:29pm. 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 7 Number of interviews conducted with residents: 0 (1 interview with a resident’s family member) 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

22VAC40-73-450-C

Based on a review of resident records, the facility failed to address all identified needs on comprehensive individualized service plans (ISPs) for three of the six resident files that were reviewed.

Evidence

The uniform assessment instrument (UAI) for resident #2 completed 01/05/2023 identifies disoriented – some spheres, some of the time with the following spheres affected: place, time and situation. The ISP for resident #2 completed 01/09/2023 does not address the spheres of place and situation.
The UAI for resident #3 completed 02/02/2023 identifies disoriented – some spheres, some of the time with the following spheres affected: place and time. The ISP for resident #3 completed 02/02/2023 does not address the sphere of place.
The UAI for resident #5 completed 02/20/2023 identifies disoriented – some spheres, all the time with the following spheres affected: place, time and situation. The ISP for resident #5 completed 02/20/2023 does not address the spheres of place and situation.

Plan of correction

1.) The ISP for resident #2 has been updated to address the spheres of place and situation. The ISP for resident #3 has been updated to address the sphere of place. The ISP for resident #5 has been updated to address the spheres of place and situation. 2.) All residents have the potential for the same practice to happen due to deficient practice. 3.) All current ISPs have been audited to ensure that all needs identified on the current UAI have been addressed. 4.)The Memory Care Director will monthly audits all new ISPs to ensure that all identified needs are addressed on comprehensive individualized services plans (ISPs). [SIC]

22VAC40-73-1110-B

Based on review of resident records, the facility failed to ensure that six months after placement of the resident in the safe secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.

Evidence

Resident #1 was placed in the special care unit on 01/19/2021. The six-month review of appropriateness occurred on 05/12/2021. There were subsequent reviews on 01/23/2023 and 07/19/2023. There was no annual review in 2022 documented in the record for resident #1.
Resident #5 was placed in the special care unit on 08/21/2020. The first review of appropriateness occurred on 05/12/2021, more than six months after resident #5 was placed in the special care unit. The next review occurred on 08/24/2022; more than 12 months had elapsed since the previous review.

Plan of correction

1.) Although the annual review in 2022 of resident #1 and the six month of 2021 and annual review of 2022 on resident #5 cannot be corrected the facility will ensure going forward that the six months after placement and the annual review of the appropriateness of continued residence in the special care unit will be performed on time for each resident. 2.) All residents’ files have the potential to be affected by the deficient practice. 3.) All resident files have been audited to ensure the correct review of the appropriateness of continued residence in the special care unit are of correct time frame. 4.) The Memory Care Director will conduct monthly audits on resident files to ensure the appropriate review of the appropriateness of continued residence in the special care unit is done on time. [SIC]

22VAC40-73-550-G

Based on a review of resident records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual, and to maintain

Evidence

of this review via written acknowledgment of having been so informed, which shall include the date of the review, in the resident's record. EVIDENCE:
Resident #1 was admitted to the facility on 01/19/2021. Acknowledgement of the review of resident rights for resident #1 was signed and dated by the responsible individual on 01/28/2021. No further documentation verifying annual review of resident rights and responsibilities were observed in the record for resident #1.
Resident #2 was admitted to the facility on 08/22/2021. Acknowledgement of the review of resident rights for resident #2 was signed and dated by the responsible individual on 08/22/2021. No further documentation verifying annual review of resident rights and responsibilities were observed in the record for resident #2.
Resident #6 was admitted to the facility on 08/21/2020. Acknowledgement of the review of resident rights for resident #6 was signed and dated by the responsible individual on 08/21/2020. No further documentation verifying annual review of resident rights and responsibilities were observed in the record for resident #6.

Plan of correction

1.) The rights and responsibilities of residents in assisted living facilities have been reviewed with the legal representative or responsible individual with written acknowledgement including the date of review for resident #1 and #2 and have been placed in resident’s record. Resident #6 is no longer a resident on assisted living with discharge date of 07/24/23. 2.) All residents have the potential to be affected by the deficient practice. 3.) All residents that were due an annual review of rights and responsibilities in assisted living facilities have been reviewed with their legal representative or responsible individual with a signed acknowledgement placed in their records. 4.) The Memory Care Director will conduct monthly audits to ensure that the rights and responsibilities of residents in assisted living facilities will be reviewed with each resident or his legal representative or responsible individual and have written acknowledgement of having been so informed which will include the date of the review and will be placed in the resident’s record. [SIC]

22VAC40-73-320-A

Based on a review of resident records, the facility failed to ensure the physical examination and report shall contain a description of the person's reactions to known allergies.

Evidence

The report of resident physical examination for resident #3 completed 01/09/2023 identifies penicillin as a known allergy; a description of resident #3’s reaction to penicillin is not included on the report.
The report of resident physical examination for resident #5 completed 08/21/2020 identifies sulfa as a known allergy; a description of resident #5’s reaction to sulfa is not included on the report.

Plan of correction

1.) Reactions to known allergies for both resident #3 and #5 have been identified and added to the physical examination and report for each resident and placed in each resident’s record. 2.) There is a potential for the same practice to happen for all new admissions due to deficient practice. 3.) All resident files were audited to ensure all reactions to known allergies were present in their physical examination and report. 4.) The Memory Care Director will conduct audits to ensure that all reactions to known allergies will be identified on the physical examination and report of all new admissions. [SIC]

August 29, 2023Inspection0 violations

Inspection dates

08/29/2023

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: 08/29/2023, 2:15pm to 2:40pm 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: 18 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: Reviewed staff training records 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.

May 2, 2023Inspection1 violation

Inspection dates

05/02/2023, 05/18/2023

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: 05/02/2023, 12:04pm to 1:04pm and 05/18/2023, 1:48pm to 1:58pm 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 04/06/2023 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: 19 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: 5 Number of interviews conducted with residents: 0 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 investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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. 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

22VAC40-73-650-A

Based on facility self-report, documentation review and interview with staff, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed or discontinued by the facility without a valid order from a physician or other prescriber.

Evidence

LI received a report from staff #1 on 04/06/2023 stating staff #5 reported to staff #4 at approximately 3:55am the same date that an agency nurse (staff #3) stated she gave 10mg Melatonin to residents #1 and #2. Per staff #1, this medication was not ordered by a prescriber for the above referenced residents.
Per the Medication Administration Records (MARs) and prescriber orders, resident #1 receives Melatonin Tablet 5mg, give 5mg by mouth at bedtime for insomnia and resident #2 receives Melatonin Oral Tablet 3mg, give 1 tablet by mouth at bedtime for insomnia.
Per interview with staff #1, the prescribed Melatonin for both resident #1 and resident #2 is packaged by the pharmacy in strip packaging, along with other prescribed medications for each resident. Staff #1 reported she did not know where the additional Melatonin came from.
Per written statement by staff #3, she gave resident #2 an additional 3mg of Melatonin “with the intention of helping him sleep.”
Per written statement by staff #4, staff #5 reported that when he questioned staff #3 about administering “medications that weren’t prescribed,” staff #3 stated it was not an issue because it was “an over-the-counter medication.” Staff #5 also reported to staff #4 that staff #3 had given resident #1 “extra melatonin out a separate supply in a bottle – he did not know where the supply came from but thought he heard the nurse say it was 10mg.”
Per written statement by staff #5, he was asked by staff #3 to stay with resident #2, “cause she had given him a Melatonin.” In addition, staff #5 also stated with regard to resident #1, staff #3 “had taken melatonin out of an over-the-counter bottle and gave her one from it as well.”
Per written statement by staff #6, staff #6 witnessed staff #3 administer additional Melatonin to both resident #1 and resident #2.

Plan of correction

1.) In-service/education provided to all staff regarding mandated reporters, resident rights, and abuse, neglect, exploitation, and misappropriation of property. 2.) In-service/education provided to all nursing staff with policies and procedures on abuse, neglect, exploitation and misappropriation, use of restraints, medication utilization, administrating medication, medication errors, documentation of medication administration, medication administration schedule, labeling of medication, administrating oral medications, and medication orders. 3.) Agency nurse was placed on do not return to this facility with her agency.

March 9, 2023Complaint survey1 violation

Inspection dates

03/09/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 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: 03/09/2023, 11:10am to 1:55pm 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 01/03/2023 regarding allegations in the areas of: resident care and related services, resident accommodations and related provisions, and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 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 investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: resident accommodations and related provisions. A violation notice was issued; any violation(s) not related to the complaint 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. 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-E

Based on information obtained from staff interviews, the facility failed to ensure all furnishing, fixtures, and equipment, including furniture, windows coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition.

Evidence

Staff #1 and staff #2 confirm the clothes washing machines and dryers were out of order during part of the month of December 2022. 2. Staff #2 reports parts were ordered on 12/22/2022, delivered on 12/23/2022, and repairs were made to the appliances on 12/26/2022. 3. Staff #1 and staff #2 report the appliances were operational following the repair on 12/26/2022, however there was an accumulation of unwashed laundry at that time due to time the equipment was out of order, thus resulting in a shortage of residents’ available clean clothing.

Plan of correction

1. Washing machines were repaired on 12/26/2022 and have been operational sine. 2. Preventive Maintenance scheduled once a month to above equipment. 3.Additional staffing hours have been added for laundry: PM shift added on Mondays, Wednesdays, Fridays and Saturdays.

December 16, 2022Inspection0 violations

Inspection dates

12/16/2022

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: 12/16/2022 Begin: 12:30pm-1:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 10, 2022Inspection11 violations

Inspection dates

11/10/2022

Areas reviewed

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: 11/10/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Begin: 10:20 am: End: 6:20pm 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 Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations

22VAC40-73-650-C

Based on review of resident records, the facility failed to have a physician order reviewed and signed within 14 days for one resident.

Evidence

Resident #10 was prescribed Buspirone tablet, 15 mg, one tablet by mouth three times daily on 2/28/22. On the date of the inspection (11/10/22), this order had not been signed.

Plan of correction

1. Provider who ordered medication for resident #10 is no longer seeing residents at this Center. The order has been discontinued and re-ordered by the current provider. 2. All provider orders have the potential to be affected by the deficient practice. 3. Providers will be re-educated regarding the 14 day signature. The Memory Care Director will perform an audit of all records to ensure all orders are signed. 4. An audit will be conducted monthly to ensure all orders are signed as appropriate. [sic]

22VAC40-73-410-A

Based on resident record review, the facility failed to include a signed and dated document to show that residents and/or their responsible party had received orientation to the facility for four residents.

Evidence

Resident #5 was admitted to the facility on 8/22/21.
Resident #6 was admitted to the facility on 10/26/22.
Resident #7 was admitted to the facility on 6/1/22.
Resident #8 was admitted to the facility on 6/1/22.
There was no was no documentation in the above mentioned resident’s files to show the resident or his/her responsible party had received orientation to the facility.

Plan of correction

1. Residents 5, 6, 7 and 8 were contacted and orientation was provided, and questions were reviewed. 2. All residents have the potential to be affected by the deficient practice. 3. Administrator provided education to the new Memory Care Director to create new admission packets to include documentation related to unit orientation for new residents and/or their family. 4. Audits will be conducted for new admissions. [sic]

22VAC40-73-680-D

Based on resident record review and the medication cart audit, the facility failed to administer medications consistent with the standards outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDNECE: 1. Bre Ellipta Inhaler 100-25, one puff by mouth daily for Resident #6 was found in the medication cart with no open date. 2. Fluticasone Spray 50mcg one spray in each nostril every day for Resident #11 was found in the medication cart with no open date. 3. Dorzolamide Solution 2% eye drops, one drop in each eye twice daily for Resident #12 was found in the medication cart with no open date.

Plan of correction

1.All medications for residents #6, #11 and #12 were correctly dated. 2. All resident medications have the potential to be affected by the same deficient practice. 3. Education will be provided for all licensed team members. 4. The Memory Care Director will audit medication carts four times monthly to ensure medications are properly maintained. [sic]

22VAC40-73-1130-A

Based on observations and staff interview, the facility failed to maintain at least two direct care staff members awake and on duty and for every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit.

Evidence

The LI observed only two direct care staff persons; Staff #5 and #6; on the special care unit from 2:15pm-2:35pm; 2:44pm-2:47pm; 2:54pm-3:03pm.
Staff #5 and #6 confirmed they were the only two direct care staff persons available on the special care unit from the above-mentioned times.

Plan of correction

1. The new Director of Memory Care and scheduler have both been educated regarding the staffing requirements. 2. The facility is at risk for the same deficient practice. 3. Staff breaks will be scheduled going forward, to ensure the required staff are on the unit. 4. The Administrator or Memory Care Director will audit weekly to ensure appropriate staffing. [sic]

22VAC40-73-250-D

Based on review of staff records, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submit the results of a tuberculosis risk assessment.

Evidence

Staff #2 was hired on 9/30/22. According to Staff #4 there was not a tuberculosis risk assessment available in Staff #2’s file.

Plan of correction

1. A tuberculosis risk assessment was conducted for Staff #2. 2. All team members have the potential to be affected by the deficient practice. 3. All team member files were audited to ensure risk assessment results were present and conducted if needed. 4. Human Resources Manager will audit files to ensure risk assessments are included for any new hire and team members done annually. [sic]

22VAC40-73-870-E

Based on observations made during the tour of the building, the facility failed to keep all furnishings, fixture, and equipment clean and in good repair and condition.

Evidence

Six of the dining room chairs were found to have dark brown stained areas on the seat cushions of the chairs. LI only looked at six chairs because the remainder of the chairs were occupied by residents.
The area under the sink off of the dining room was found to have a dried brown substance approximately one foot by one foot in area which has left a stain.

Plan of correction

1. (A) Chairs were cleaned by housekeeping staff. Administration working on a plan to have seats cushions re-upholstered. (B) Housekeeping will clean under the sink in the memory care diet kitchen area. 2. All areas have the potential to be impacted. 3. An audit of all like furniture and sink spaces will be conducted and issues addressed. 4. Housekeeping Director will conduct a monthly audit to ensure furniture and spaces under sink is clean. [sic]

22VAC40-73-380-A

Based on resident record review, the facility failed to obtain the following personal and social data prior to or at time of the admission for one resident.

Evidence

Resident #7 was admitted to the facility on 6/1/22. The following areas were left blank on Resident #7’s personal and social data: local department of social services, other agency, previous mental health, current behaviors, and substance abuse history.

Plan of correction

1. Resident Personal Social Data form for resident #7 was incomplete. Memory Care Director will meet with family to complete the form. 2. All residents have the potential to be affected by the same practice. 3. All resident records will be reviewed to ensure all forms are complete. 4. The Administrator or designee will do a final review [sic]

22VAC40-73-250-C

Based on staff record review, the facility failed to maintain verification that a staff person received a copy of his/her current job description.

Evidence

Staff #3 was hired on 9/20/22. According to Staff #4 there was no job description available in Staff #3’s file.

Plan of correction

1. Copy of Staff #3’s Job Description was obtained and placed in file. 2. All have the potential to have job descriptions missing from their files. 3. All records were reviewed to ensure there is a signed job description on file for each person. 4. Human Resources will review each new hire’s record to ensure job descriptions are maintained. [sic]

22VAC40-73-660-A-1

Based on observations made during the tour of the building, the facility failed to store all medications in a locked storage area.

Evidence

When LI was walking by the medication cart there were several medication cards laying on top of the medication cart to include: Metoprol Suc Tab, 25 mg ER; Folic Acid 1,000mcg; Zinc Sulfate 220mg; Buspirone 5mg; Buspirone 10mg; Losartartan 50mg; Mucus Relief 600mg ER; Furosemide 20mg; Acetaminophen 325mg; Asprin 81mg; Docusate Sodium 100mg; Dutasteride .5mg. These medications were left unattended and unlocked on the date of the inspection; 11/10/22.

Plan of correction

1. Education will be provided to the nurse. 2. There is a potential for the same practice to happen due to deficient practice. 3. Education will be provided to all licensed team members. 4. Memory Care Director will conduct periodic audits throughout the month to ensure no medications are left unattended. [sic]

22VAC40-73-390-C

Based on resident record review, the facility failed to update the residential agreement with the facility whenever there are changes to any policy or information referenced.

Evidence

On 6/1/22, a new licensee assumed responsibility for this facility. Residents #5, #7, and #8 were residing at this facility prior to the 6/1/22 takeover. Resident #5, #7, nor #8 had any signed and dated documentation in their files to show the update or change to the original agreement regarding the new licensee.

Plan of correction

1. An addendum to the residential agreement with the facility will be sent to each resident and/or resident representative to extend the agreement to include the new licensee. 2. All residents have the potential to be affected by the same deficient practice. The agreement addendum will be sent to all residents and/or resident representatives. 3. Education provided to the Admissions Director regarding new ownership. 4. An audit will be conducted to ensure appropriate agreement is in place for new admissions. [sic]

22VAC40-73-610-B

Based on observations made during the tour of the building, the facility failed to have the menu for the current week dated and posted.

Evidence

The menu posted in the dining area was dated as “Week 4, Sunday-Saturday”, but no dates were specified.

Plan of correction

1. When posted, menus will have a date associated with the week. 2. All were potentially affected. 3. Administrator provided education to the Dietary Manager. 4. The Memory Care Director will conduct monthly audits to ensure corrective measures remain in place. [sic]

August 4, 2022Inspection2 violations

Inspection dates

08/04/2022

Areas reviewed

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: 08/04/2022 2:20pm-5:01pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 08/04/2022 2:20pm-5:01pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations

22VAC40-73-660-A

Based on observations made during the tour of the building, the facility failed to properly store medications which are administered by the facility.

Evidence

Resident # 3 had a 7 ounce bottle of Anti Dandruff Shampoo 1% with a pharmacy label stating it was to be used topically every Tuesday and Friday on shower days. This bottle was found in Resident #3’s shower on the date of the inspection.

Plan of correction

1.Antidandruff shampoo was removed from Resident #3's room on 08/04/22. 2. Staff and resident responsible parties will be educated on proper storage of medication/prescriptions. 3.Audit to be completed by the Director of the unit 3x/week for 2 weeks, then 1x/week for 2 weeks, and then monthly for 2 months. [sic]

22VAC40-73-860-I

Based on observations made during the tour of the building, the facility failed to store all hazardous materials in a locked area.

Evidence

Resident #4 was observed to have a 11.8 ounce delicate petals body lotion on her dresser; a 15 ounce bottle of V05 extra body with collagen hair conditioner and a 7.5 ounce Derma Vena Skin and Hair Cleanser in her shower. The hair cleanser had a label on the back that stated, “Keep out of reach of children”. There was a 21 ounce Jergens Ultra Healing Extra Dry Skin Moisturizer, a .85 ounce container of anticavity toothpaste that had a label stating, “Keep out of reach of children under six”, a 4 ounce Colgate Anticavity Fluoride Toothpaste with a label stating, “Keep out of reach of children under six years of age. If more than used for brushing is accidently swallowed get medical help or contact a poison control center right away” all located on the bathroom sink area.

Plan of correction

1. Hazardous materials were removed from resident #4's room on 8/4/22. 2. Staff and Resident responsible parties will be educated on proper storage of hazardous materials. 3. Audit to be completed by Director of the unit 3x/week for 3 weeks, then 1x/week for 2 weeks, and monthly for 2 months. [sic]

April 18, 2022Inspection2 violations

Inspection dates

04/18/2022

Areas reviewed

Comments

The licensing inspector for Memory Care at Bristol conducted the initial announced inspection on 04/18/2022. Residents in care were observed and staff and resident interactions were observed. The building and grounds were observed and the first aid kit was checked. An exit meeting was held with the administrator and key staff on the date of the inspection, 04/18/2022. Two violations are being cited as a result of the inspection. Please develop a plan of correction for each violation cited along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days of receipt (05/13/2022). If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations

22VAC40-73-860-I

Based on observations made during the tour of the building, the facility failed to keep all cleaning supplies in a locked area.

Evidence

The cabinet under the fish tank located in the common room had a container of disinfectant wipes stored there. These wipes have a label on them that says "Keep out of the reach of children" indicating it is a hazardous material.

Plan of correction

On 4/13/2022 cleaning supplies were removed from cabinet under fish tank in communal area. Residents who can open cabinets have the potential to be affected by this. Direct Care Staff were provided with education on hazardous material storage. Weekly audits will be completed to monitor for appropriate hazardous material storage for 3 months. [sic]

22VAC40-73-710-C

Based on resident record review and observations made during the tour of the building, the facility failed to have a physician's order for bed rails for one resident in care.

Evidence

Resident #1 was observed to have half rails on her bed, she was not able to voice the purpose of the rails and there was no physician's order in her file to document the need for the half rails on her bed.

Plan of correction

Resident #1 bed rails were removed from resident's bed. All other residents were reviewed for presence of bed rails, none identified. Director of Life Enrichment educated on process for addition and presence of bedrails. Monitor to ensure any new admissions that come in with bed rails in place have physician order and appropriate ISP update/monitoring. Audit weekly for 3 months. [sic]