Inspection Reports for Brookdale Bristol
375 Liberty Pl, Bristol, VA 24201, United States, VA, 24201
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Inspection Report
Monitoring
Census: 89
Deficiencies: 0
Apr 28, 2025
Visit Reason
The inspection was a monitoring visit conducted on April 28, 2025, to review resident care and related services at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident records and staff interviews.
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 89
Deficiencies: 0
Apr 28, 2025
Visit Reason
The inspection was a monitoring visit conducted by the Virginia Department of Social Services to review resident care and related services at the facility.
Findings
The inspection found no violations of applicable standards or laws. The inspection summary will be posted publicly within five business days.
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 91
Deficiencies: 6
Mar 12, 2025
Visit Reason
The inspection was a renewal inspection conducted on March 12 and 13, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to incomplete resident personal/social information, incomplete individualized service plans, failure to follow prescribed diets, incomplete oxygen therapy orders, and maintenance issues including carpet stains and non-functioning bathroom exhaust fans. Plans of correction were submitted addressing these deficiencies.
Deficiencies (6)
| Description |
|---|
| Failed to ensure all required personal and social information was obtained prior to or at admission. |
| Failed to ensure all required information is included on the comprehensive individualized service plan (ISP). |
| Failed to ensure prescribed diets were prepared and served according to physician's orders. |
| Failed to ensure oxygen therapy orders contained all required information. |
| Failed to maintain interior and exterior of buildings in good repair and kept clean and free of rubbish (carpet stains observed). |
| Failed to ensure ventilation to the outside to eliminate foul odors (bathroom exhaust fan not working). |
Report Facts
Number of residents present: 91
Number of resident records reviewed: 9
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Named as the licensing inspector conducting the inspection |
| Health and Wellness Director | Named as responsible for reviewing diet orders and oxygen therapy orders, and conducting audits | |
| Dining Services Coordinator | Named as responsible for reviewing diet orders and participating in clinical and dining services meetings | |
| Maintenance Director | Named as responsible for auditing bathroom exhaust fans and preventive maintenance |
Inspection Report
Monitoring
Census: 75
Deficiencies: 0
Apr 26, 2024
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review personnel standards and compliance at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed one staff record with no deficiencies noted.
Report Facts
Number of residents present: 75
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 65
Deficiencies: 9
Feb 29, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations including failure to ensure medication aides completed required continuing education, lack of current first aid certification for direct care staff, missing verification of admission interviews for residents, incomplete fall risk assessments, failure to check sex offender registry prior to admission, incomplete individualized service plans, and maintenance issues such as unclean resident rooms and foul odors.
Deficiencies (9)
| Description |
|---|
| Failure to ensure medication aides completed required continuing education. |
| Failure to ensure direct care staff maintained current first aid certification. |
| Failure to maintain verification of documented admission interviews for five residents. |
| Failure to complete a written fall risk rating for one resident by the time the comprehensive ISP was completed. |
| Failure to review and update fall risk ratings at least annually for three residents. |
| Failure to ascertain whether a potential resident is a registered sex offender prior to admission. |
| Failure to include all required information on the comprehensive individualized service plan for two residents. |
| Failure to maintain the interior and exterior of all buildings in good repair and free of rubbish, including dirt, debris, clutter, stains, and cracks. |
| Failure to ensure all buildings are well-ventilated and free from foul, stale, and musty odors. |
Report Facts
Number of residents present: 65
Number of resident records reviewed: 14
Number of staff records reviewed: 5
Number of resident interviews conducted: 4
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 60
Deficiencies: 0
Nov 15, 2023
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review personnel standards at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The inspector completed a tour of the physical plant and conducted staff interviews without identifying any deficiencies.
Report Facts
Number of residents present: 60
Number of staff interviews: 3
Number of staff records reviewed: 0
Inspection Report
Monitoring
Census: 60
Deficiencies: 2
Nov 15, 2023
Visit Reason
The inspection was a monitoring visit conducted on November 15 and December 19, 2023, following a self-reported incident received on September 19, 2023, regarding allegations related to resident care and medication administration.
Findings
The inspection found non-compliance with applicable standards related to medication management, including failure to keep medications in pharmacy-issued containers with proper labeling and failure to administer medications according to physician orders. Violations were documented and a violation notice was issued to the facility.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications remained in the pharmacy issued container with the prescription label or direction label attached until administered. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, resulting in administration of morphine doses exceeding the prescribed amount. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of staff interviews conducted: 4
Dates of inspection: 2
Date of self-reported incident: Sep 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Named as the current inspector conducting the inspection |
| Staff #1 | Named in medication administration deficiency and corrective action | |
| Staff #2 | Named in medication administration deficiency and corrective action | |
| Staff #3 | Named in relation to hospice employee converting morphine to prefilled syringes |
Inspection Report
Monitoring
Census: 55
Deficiencies: 1
Aug 2, 2023
Visit Reason
The inspection was a monitoring visit conducted on August 2, 2023, following a self-reported incident received on June 7, 2023, regarding allegations related to resident care and medication administration.
Findings
The inspection found non-compliance with applicable standards related to medication administration. Specifically, a medication error occurred where a resident was administered four times the prescribed dose of Lorazepam due to staff misunderstanding the order.
Deficiencies (1)
| Description |
|---|
| Failed to administer medications in accordance with physician's instructions and standards of practice, resulting in a medication error where a resident received four doses (8mg total) of Lorazepam instead of the prescribed 2mg on 06/05/2023. |
Report Facts
Residents present: 55
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 2
Medication error dose: 8
Corrective action notice date: Jun 7, 2023
Training completion deadline: Aug 31, 2023
Monitoring duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff #1 | Staff member who administered incorrect medication dose and was counseled | |
| Staff #2 | Staff member interviewed regarding medication error | |
| Staff #3 | Staff member who discovered the medication error and was interviewed |
Inspection Report
Monitoring
Census: 55
Deficiencies: 3
Apr 11, 2023
Visit Reason
The inspection was a monitoring visit to review compliance with resident care, related services, and building and ground standards at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards and laws related to the physical plant, specifically failure to keep all interior areas of the building in good repair and clean, with documented violations issued to the facility.
Deficiencies (3)
| Description |
|---|
| The transition strip from laminate flooring to carpet in hallway A-1 outside the activity room had a raised and torn piece of carpet approximately 12 inches long, presenting a trip hazard. |
| A brown stain approximately eight to ten inches was present on the carpet in hallway B-3 at the door in front of the stairway next to the elevator. |
| The transition strip from laminate flooring to carpet on the second floor hallway A-2 outside the medication room had a raised piece of carpet approximately 18 inches long, presenting a trip hazard. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 3
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Inspector conducting the monitoring visit and named in contact information |
Inspection Report
Renewal
Census: 55
Deficiencies: 5
Feb 22, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to follow infection control policies related to medication cart labeling, incomplete Uniform Assessment Instruments (UAIs), inadequate Individualized Service Plans (ISPs) addressing resident needs, failure to provide care as specified in ISPs, and maintenance issues with flooring and cleanliness.
Deficiencies (5)
| Description |
|---|
| Facility failed to follow infection control policy; unlabeled glucometers on medication carts. |
| Facility failed to ensure private pay Uniform Assessment Instruments (UAIs) were completed as required. |
| Facility failed to address all identified needs on Individualized Service Plans (ISPs) for four residents. |
| Facility failed to ensure care and services specified in the Individual Service Plan (ISP) were provided to each resident. |
| Facility failed to keep all interior areas of the building in good repair and clean, including trip hazards from raised carpet and stains. |
Report Facts
Number of residents present: 55
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
Inspection Report
Renewal
Deficiencies: 0
Feb 17, 2022
Visit Reason
An unannounced mandated license renewal inspection was conducted at Brookdale Bristol on 02/17/2022 to review resident files, required postings, medication administration, meal service, and staff-resident interactions.
Findings
No violations were cited as a result of the inspection. The inspection included file reviews, medication cart and records checks, observation of meals and interactions, and an exit meeting with the administrator and key staff.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 3, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation in response to a complaint received on 11/03/2021 regarding issues with cleanliness and resident care.
Findings
Interviews with residents and observations of the physical plant did not support the allegations in the complaint, and the complaint was determined to be not valid.
Complaint Details
The complaint was related to allegations of issues with cleanliness and resident care. The complaint was investigated and determined to be not valid.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Conducted the complaint inspection |
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Mar 31, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection reviewed resident and staff records, schedules, oversight reports, and emergency drills documentation. No violations were found and no deficiencies were issued.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Staff schedules reviewed: 14
Inspection Report
Monitoring
Deficiencies: 1
Mar 21, 2021
Visit Reason
A monitoring inspection was initiated due to a self-reported incident involving allegations in the areas of resident care, conducted remotely due to a state of emergency health pandemic.
Findings
The investigation confirmed non-compliance with medication administration standards, specifically a medication error where a staff member administered artificial nail glue instead of prescribed eye drops to a resident, resulting in injury and subsequent medical treatment. Violations were issued and corrective actions planned.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's instructions and standards of practice, resulting in a medication error causing harm to a resident. |
Report Facts
Incident date: Mar 21, 2021
Staff termination date: Mar 24, 2021
Retraining deadline: Apr 3, 2021
Monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Inspector | Current inspector conducting the monitoring inspection |
| Staff #1 | Staff member who administered incorrect medication and was suspended then terminated | |
| Director of Nursing | Contacted for investigation and involved in follow-up discussions |
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