Virginia DSS · Assisted Living Facility

Brookdale Danville Piedmont

📍 149 Executive Court, Danville, VA, 24541

ID 23541Two Year licenseActive
8
Inspections
On record
7
With violations
Visits that cited something
1
Clean visits
Nothing cited
41
Violations cited
Individual findings
26
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Brookdale Danville Piedmont was inspected 8 times between December 11, 2020 and December 11, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 41 violations under 26 distinct standards.

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

VDSS publishes inspections on a rolling window. 6 of these 8 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
12/30/2027
Administrator
Carole Maxwell
Licensing inspector
Cynthia Ball
Inspector phone
(540) 309-2968
Approved for
Assisted Living · Non-Ambulatory

Inspection History

8

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

December 11, 2025Inspection6 violations
Inspection dates
12/11/2025
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 12/11/2025 8:45am until 3:30pm 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: 45 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that each staff person submitted the results of a tuberculosis risk assessment on or within seven days prior to the first day of work at the facility.
Evidence
  1. The record for staff person 2, whose first day of work was 08/10/2025, has documentation that the screening for tuberculosis was not completed until 08/11/2025.
  2. The record for staff person 3, whose first day of work was 11/04/2025, has documentation that the screening for tuberculosis was not completed until 11/06/2025.
Plan of correction
The following is the Plan of Correction for Brookdale Danville Piedmont regarding the Statement of Deficiencies dated 12/11/2025 and received 12/15/2025. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to the delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. • Unable to retroactively correct Tuberculosis Risk Assessment dates for Staff # 2 and 3. • Executive Director or designee will provide retraining for Health and Wellness Director, Health and Wellness Coordinator, and Business Office Coordinator on Risk Assessment by 12/31/2025. • Executive Director or designee will audit current personnel files for a completed Tuberculosis Screenings by 12/31/2025. • Business Office Coordinator, Health and Wellness Director, or designee will confirm (or provide as needed) the tuberculosis risk assessment for each associate on or within seven (7) days prior to the first day of work. • To assist with ongoing compliance, the Executive Director or designee will audit new hire staff record for Tuberculosis Screenings once a week for eight (8) weeks.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that resident physical examination were completed within 30 days preceding admission to the facility.
Evidence
  1. The record for resident 2, admitted to the facility on 04/18/2025, has documentation on the first page of the residents physical examination that the date the physical examination was completed was 11/12/2024.
Plan of correction
• Unable to retroactively correct date or verbiage on resident physical examination. • Executive Director or designee will provide retraining for Sales Manager and Health and Wellness Director on requirement for medical provider to conduct a resident’s physical examination is within 30 days of admission or prior to admission. • Executive Director, Sales Manager, Health & Wellness Director, or designee will review and verify resident medical provider physical visit is within 30 days of admission or prior to move in. To assist with on-going compliance, the Executive Director or designee will audit new admission medical provider physical visit date monthly for two (2) months.
22VAC40-73-640-A
Based on observations of the facility medication carts, the facility failed to implement their medication management plan (MMP) in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility MMP has documentation on page 6 under Maintenance of Scheduled II-V Medications that medications will be counted by a licensed nurse/RMA from the off-going shift and from the oncoming shift at the beginning of each shift or whenever a change is made within the shift. Both staff’s signatures and the count of bingo cards and sheets will be documented on either the Schedule II count sheet provided by the communities preferred pharmacy and the communities controlled medication inventory sheet.
  2. The facility Controlled Substance/MAR Change of Shift Audit forms for the Mount Cross medication cart did not contain documentation of the signature of the staff person who counted the controlled medications on 12/01/2025 at 11pm off-going, 12/09/2025 at 3pm off-going, 12/10/2025 at 7am on-coming.
  3. The facility Controlled Substance/MAR Change of Shift Audit forms for the T-Bird medication cart did not contain documentation of the signature of the staff person who counted the controlled medications on 12/07/2025 at 11pm off-going, 12/08/2025 at 3pm off-going and oncoming and 12/08/2025 at 11pm off-going.
Plan of correction
• Unable to retroactively correct MAR Change of Shift Audit forms and Controlled Substance forms. • Health and Wellness Director or Health and Wellness Coordinator or designee will provide retraining to current Medication Technicians regarding adding signatures to MAR Change of Shift and Controlled Substance forms. • To assist with ongoing compliance, the Health and Wellness Director, Health and Wellness Coordinator, or designee will conduct reviews of the MAR Change of Shift and Controlled Substance documentation for four (4) weeks and then monthly for six (6) months.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that resident individualized service plans (ISPs) were updated as needed to reflect changes in a residents condition.
Evidence
  1. The uniform assessment instrument (UAI) dated 11/20/2025 in the record for resident 1 has documentation that the resident is incontinent of bladder weekly or more. The ISP dated 11/20/2025 is inconsistent as it does not reflect this identified need.
Plan of correction
• Unable to retroactively correct individualized service plan for Resident 1. • Executive Director, Health and Wellness Director, or designee will update Resident 1’s ISP and UAI by 12/31/2025. • Executive Director will provide retraining for Health and Wellness Director and Health and Wellness Coordinator on updating both the individualized service plan and the uniform assessment instrument when there is a change in residents condition. • To assist with ongoing compliance the Health and Wellness Director, Health and Wellness Coordinator, or designee will conduct a review of 5% of current residents individualized service plans and uniform assessment instruments weekly for four (4) weeks and then monthly for six (6) months.
22VAC40-73-980-A
Based on observations of the facility first aid kit, the facility failed to ensure that items in the kit did not have expirations dates that had already passed.
Evidence
  1. At approximately 10:10am on the day of on-site inspection, the facility first aid kit contained a bottle of Mckesson Premium Hand Sanitizer with Aloe that had an expiration date of September 2025.
Plan of correction
• Violation was resolved on 12/11/25 by 1st shift supervisor RMA. • Executive Director or designee will provide retraining to Health and Wellness Director and Health and Wellness Coordinator on first aid supplies being replaced before expiration date. • Health & Wellness Director or designee will audit first aid kit for items to be clearly marked with expiration date. • To assist with ongoing compliance with state regulations, the Health and Wellness Director, Health and Wellness Coordinator, or designee will review the first aid kit in the medication room monthly for three (3) months and replace upcoming items due to expire.
22VAC40-73-610-B
Based on observations of the facility physical plant, the facility failed to ensure that the current week’s menu was post in an area conspicuous to residents.
Evidence
  1. At approximately 9:08am on 12/11/2025, the day of on-site inspection, the facility menu that was posted was for the previous week of 11/30/2025 through 12/06/2025.
Plan of correction
• Violation was resolved on 12/11/25 by Executive Director. • Executive Director or designee will provide retraining to the Dining Services Manager regarding posting current week’s menu in an area conspicuous to residents. • The Dining Services Manager or designee will post weekly menu. • To assist with ongoing compliance the Executive Director or designee will conduct a review of the menu posted weekly for four (4) weeks and then monthly for six (6) months.
December 11, 2025Inspection0 violations
Inspection dates
12/11/2025
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: 12/11/2025 8:45am until 3:30pm 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 08/02/2025 regarding allegations in the area(s) of: Resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 45 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 interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 14, 2025Inspection7 violations
Inspection dates
04/14/2025
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 04/14/2025 8:20am until 2:30pm 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: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The LI reviewed standards 22VAC40-73-1010- Applicability and 22VAC40-73-1040- Door and windows with the facility Administrator for clarification of mixed population regulations. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observations of the facility physical plant and resident record review, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room only if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.
Evidence
  1. A bottle of DG Health Extra Strength Antacid Tablets was observed sitting out on a shelf in the room for resident 1. The record for resident 1 does not have a physician order for this medication. The history and physical dated 12/10/2024 has documentation that resident 1’s medications are administered by staff. The UAI dated 12/13/2024 in the record for resident 1 has documentation that medications are administered by a Layperson.
  2. A bottle of Tylenol Extra Strength 500mg, an Albuterol Sulfate Inhaler, a tube of Original Triple Antibiotic Ointment, a tube of Clotrimazole 1% cream and a tube of Nystatin 100,000 cream was observed sitting out in a basket on the dresser in the room for resident 2. The record for resident 2 only contained a physician order for Nystatin 100,000 cream PRN but did not include orders that resident 2 can self-administer this medication. The history and physical dated 07/02/2024 has documentation that resident 2’s medications are administered by staff. The UAI dated 04/01/2025 in the record for resident 2 has documentation that medications are administered by a Layperson.
Plan of correction
Medication was removed immediately from resident 1 room. •The empty bottle of Tylenol, along with the medications were removed immediately from resident 2 room. •To assist with ongoing compliance the Health and Wellness Director, Health and Wellness Coordinator, or designee will conduct room sweeps of all resident rooms to whom staff administer medication, to check for any medication in their possession. This will be conducted weekly for four (4) weeks, and monthly for six (6) months. •Health and Wellness Director and Health and Wellness Coordinator or designee will re-inservice clinical staff to report medications seen in a resident room. Completion date: 05/14/25. •To assist with compliance the Executive Director or designee will communicate to all residents and families if medications are ordered to be administered by staff that all medications must be given to the Health and Wellness Director or Health and Wellness Coordinator. Completion date: 05/14/25.
22VAC40-73-970-E
Based on review of the facility fire and emergency evacuation drills, the facility failed to ensure that all required information was included on the drill log sheets.
Evidence
  1. The facility Logbook Documentation sheets for fire drills dated 01/24/2025, 02/28/2025 and 03/27/2025 does not contain required documentation for the method used for notification of the drill; any special conditions simulated; weather conditions; and problems encountered, if any.
Plan of correction
•To assist with ongoing compliance with state regulations, the Executive Director or designee will verify correct drill log sheets are used for fire and emergency evacuation drills and will re-inservice the Maintenance Manager on the use of the drill log sheets. Completion date: 05/14/25.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.
Evidence
  1. A container of Waxman Kleen Freak Disinfecting Wipes was observed out on a shelf in the Spa Room at 8:41am on the day of On-site inspection. The door to the Spa Room was observed to be unlocked.
Plan of correction
•To assist with ongoing compliance with state regulations, the Health and Wellness Director and Health and Wellness Coordinator or designee will re-inservice staff on the importance of keeping the spa door locked. Completion date: 05/14/25.
22VAC40-73-680-C
Based on observations during the facility morning medication pass conducted on 04/14/2025, the facility failed to ensure that resident medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule.
Evidence
  1. During the morning medication pass conducted on 04/14/2025, the LI observed that the 8am medications for residents 2 and 8 were not administered to these residents until after 9:28am on the day of on-site inspection.
Plan of correction
•To assist with medication being administered in compliance with state regulations, the Health and Wellness Director, Health and Wellness Coordinator, or designee will review and adjust medication times for each resident. Completion date: 05/14/25.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed/updated when a change in resident condition occurred.
Evidence
  1. The uniform assessment instrument (UAI) dated 04/01/2025 in the record for resident 2 has documentation that the resident requires mechanical assistance with transferring. The ISP dated 04/01/2025 in the r4ecord for resident 2 does not have documentation of this identified need or services to be provided for transferring assistance.
  2. The record for resident 5 has documentation for Home Health notes from 01/17/2025 to current for skilled nursing for wound care to the residents right lower extremity, right foot and left second toe. The ISP dated 01/24/2025 in the record for resident 5 does not address the identified need for Home Health services for wound care needs for this resident.
Plan of correction
•Unable to retroactively correct Individualized Service Plans for resident number 2 and resident number 5. •Individualized Service Plan for resident 2 was updated 04/15/25 and reflects same as UAI. •Individualized Service Plan for resident 5 was updated 04/15/25 and reflects Home Health. •To assist with ongoing compliance, the Health and Wellness Director and Health and Wellness Coordinator or designee will conduct a review of 5% of current residents ISP’s and UAI’s for resident care needs weekly for four (4) weeks, and monthly thereafter for six (6) months.
22VAC40-73-260-A
Based on staff record review, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment.
Evidence
  1. The record for staff person 2, hired on 07/15/2024, has documentation that the employee did not receive certification in first aid until 02/26/2025. In an interview with staff person 4 on the day of on-site inspection, staff person 4 expressed that no other certification in first aid was available for review for staff person 2.
Plan of correction
The following is the Plan of Correction for Brookdale Danville Piedmont regarding the Statement of Deficiencies dated 04/14/2025 and received 04/15/2025. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is a submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to the delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. •Violation was resolved on 04/14/25. •Plan was put in place on 04/22/25 for Health and Wellness Director, Business Office Coordinator, or designee to request certification certificate from new hires upon hire. •In the absence of certification the Health and Wellness Director or designee will schedule a class and verify the new hire attends training and attains certification within sixty (60) days of employment. •To assist with ongoing compliance the Executive Director or designee will audit certification tracker monthly for 6 months.
22VAC40-73-640-A
Based on observations of the facility medication carts, the facility failed to implement their medication management plan (MMP).
Evidence
  1. The facility MMP has documentation on page 7 that medications that have expired or have been discontinued will be disposed of per policy.
  2. The facility medication cart for the T-Bird Hall contained an opened Toujeo Solostar Insulin pen in a pharmacy labeled bag for resident 6 with pharmacy instructions to discard 56 days after opening or reconstituting. The bag has documentation that the insulin was opened on 02/07/2025, which would require discarding of this medication by 04/05/2025.
  3. The facility medication cart for the T-Bird Hall contained an opened Lantus Insulin vial for resident 7. The vial did not contain a open/discard date to insure that the medication is disposed of 28 days after opening per manufacturer inspections.
Plan of correction
•The Toujeo Solostar Insulin pen was removed from the medication cart on 04/14/25 and discarded. •The Lantus Insulin vial was removed from the medication cart on 04/14/25 and discarded.. •Health and Wellness Director, Health and Wellness Coordinator, or designee will conduct cart checks to assist with ongoing compliance, and remove discontinued or expired medications. This will be conducted weekly for four (4) weeks. •To assist with ongoing compliance, the Health and Wellness Director, Health and Wellness Coordinator, or designee will conduct cart checks weekly for four (4) weeks and then monthly for six (6) months, to verify all medications are dated.
December 12, 2023Inspection4 violations
Inspection dates
12/12/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/12/2023 8:45am until 2:30pm 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: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-610-D
Based on observations and staff interviews, the facility failed to ensure that a special diet ordered by a physician was prepared and served according to physician orders.
Evidence
  1. The record for resident 3 has a physician order dated 03/17/2023 and again on 11/10/2023 that the resident is to receive a texture modified diet. The special diet board in the kitchen also has documentation that resident 3 is on a texture modified diet. The licensing inspector (LI) observed resident 3’s breakfast meal sitting on a bedside table in front of the resident on the day of inspection. 2 slices (strips) of bacon were observed on the styrofoam container. An interview was conducted with staff 6 on the day of inspection in which staff 6 expressed that slices/strips of bacon is not considered a texture modified diet.
Plan of correction
•Resident 3’s ISP was updated to show current diet order on 12-13-2023. •Direct care associates were retrained by HWD on 12-14-23 regarding serving diets as indicated in the physician order(s). •HWD/designee will review all diet orders and confirm the residents ISPs reflects any physician prescribed diet order. •To assist with ongoing compliance, the HWD/designee will review diet orders weekly for four (4) weeks to verify the diet order is correct in the resident’s ISP.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated when a significant change in a resident occurred.
Evidence
  1. The uniform assessment instrument (UAI) dated 03/18/2023 in the record for resident 3 has documentation that the resident requires physical assistance with dressing and transfers and is disoriented to some spheres some of the time with place and time being the spheres affected. The record for resident 3 also has a physician order dated 03/17/2022 and 11/10/2023 that the resident is on a texture modified diet. The ISP dated 07/06/2023 in the record for resident 3 does not address or provide documentation of services to be provided for these identified needs.
  2. The UAI dated 01/02/2023 in the record for resident 5 has documentation that the resident requires mechanical assistance with dressing. The record also has a do not resuscitate (DNR) order signed by the physician on 11/28/2023. The ISP dated 01/02/2023 in the record for resident 5 does not address or provide documentation of services to be provided for these identified needs.
Plan of correction
The following is the Brookdale Danville Piedmont Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated December 12, 2023. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. •The Health and Wellness Director (HWD)/Designee will review all resident Individualized Service Plans (ISPs) and verify the diet orders and services. •Direct care associates were retrained ISP requirements. This retraining was completed on 12-14-2023 by the Executive Director. •The ISP of Resident 3 and 5 were updated on 12-13-2023 by the HWD. •HWD/designee will review resident ISPs during care plan meetings as well as during Collaborative Care Meetings, to verify the accuracy of the assessment. •To assist with ongoing compliance, the Executive Director (ED)/designee will audit all Resident ISPs monthly for two (2) months to verify ISPs are up to date.
22VAC40-73-680-C
Based on observations of the facility morning medication pass, the facility failed to ensure that medications were administered not later than one hour after the facility standard dosing time.
Evidence
  1. The scheduled 8am medications for resident 3 were not administered until 9:18am on the day of inspection.
  2. The scheduled 8am Gabapentin 300mg for resident 4 was not administered until 9:25am on the day of inspection.
  3. The scheduled 8am medications for resident 1 were not administered until 9:44am on the day of inspection.
Plan of correction
•Medications were administered on 12-13-2023 for Resident 3, Resident 1 and Resident 4. •HWD/designee will re-train direct care staff on medication administration time frames. •To assist with ongoing compliance, the HWD/designee will audit all resident MARs weekly for four (4) weeks to verify medications are being administered within timeframes.
22VAC40-73-640-A
Based on resident record review and staff interviews, the facility failed to follow their medication management plan in regard to the ordering of medications.
Evidence
  1. The facility medication management plan has documentation that “if a medication is not available at the scheduled time of administration the pharmacy will be notified, an entry will be made in the resident log notes in the medical file and the HWD/RCC or their designee will be notified. Charting “medication not available” on the MAR alone does not fulfill this requirement.
  2. The December 2023 medication administration record (MAR) for resident 3 has a physician order dated 12/08/2023 for Cipro 500mg oral tablet, give one tablet by mouth two times a day for UTI for 7 days. Staff initials and the number 16 are listed on the MAR from 12/08/2023 through 12/12/2023 with explanation that pharmacy action is required. An interview with staff 5 on the day of inspection expressed that they were not made aware that the Cipro 500mg medication was not currently in the facility and that the medication was ordered by Hospice and the Hospice pharmacy was supposed to deliver the medication.
Plan of correction
•Hospice was contacted regarding medication for resident 3 on 12-12-23 •Retraining was completed on 12-14-2023 by the HWD regarding medications being available to follow prescribers orders •To assist with ongoing compliance, the HWD/ED/designee will conduct a weekly. medication cart audit for four (4) weeks to verify Resident medications are available.
November 15, 2022Inspection12 violations
Inspection dates
11/15/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/15/2022 9:30am until 4:30pm 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: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 13 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-700-2
Based on observations of the building, the facility failed to post “No Smoking-Oxygen in Use” signs in a room of the building where oxygen is in use.
Evidence
  1. At approximately 9:41AM, one licensing inspector (LI) observed resident 4 using oxygen in her room and multiple portable oxygen tanks. There was not a “No Smoking-Oxygen in Use” sign posted at the room.
Plan of correction
HWD/Designee will re-educate direct care staff regarding posting of No Smoking Oxygen in Use Signs when oxygen is in use. HWD/Designee will review residents on oxygen for signage of No Smoking Oxygen in Use Signs in rooms/doors
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating was updated for residents after a fall.
Evidence
  1. The record for resident 3 contained documentation by facility staff, dated 10/30/2022, that the resident fell on 10/29/2022 and was sent to the emergency room due to head injury; however, the most recent fall risk completed for the resident was dated 05/18/2022. Interview with staff 4 revealed that there is not an updated fall risk rating to reflect the fall from 10/29/2022.
  2. Progress notes for resident 5, dated 11/04/2022, indicated that the resident had fallen on that date; however, the most current fall risk evaluation completed by the facility was dated 10/12/2022.
Plan of correction
ED/HWD/designee will re-educate direct care staff regarding the fall risk rating updated after each fall. HWD/designee will review current residents fall documentation to verify the fall risk rating has been updated. To assist with ongoing compliance the ED/designee will review a sample of resident fall documentation to verify fall risk ratings is up to date, weekly for four (4) weeks.
22VAC40-73-870-A
Based on observation, the facility failed to ensure that the interior of all buildings shall be maintained in good repair.
Evidence
  1. While completing a tour of the physical plant on the date of inspection, collateral 2 observed that the wall on the left side of the dining room, next to a table and chair, had a long scratch in which a layer of paint was removed.
  2. In the conference room/therapy room on the left back side of the building, collateral 2 also observed that a portion of the ceiling was broken and a portion of the ceiling contained a dark stain around a vent.
Plan of correction
Maintenance Director/ED will repair scratch in wall in the left of the dining room and ceiling in therapy room around vent. To assist with ongoing compliance, the Maintenance Director will inspect the community building routinely for damages to walls and ceilings ekly for four (4) weeks
22VAC40-73-640-A
Based on medication cart audits, resident record review and staff interview, the facility failed to implement components of their medication management plan.
Evidence
  1. The facility’s medication management plan states the following: “A medication cart audit occurs quarterly and is completed by the HWD/RCC or their designee. An audit requires removal and reorder of all expired medications. The HWD/RCC will review the forms after the audit has been completed.” and the plan indicates that for medication refill orders medication staff are responsible for monitoring the needs for refills and the pharmacy should be notified when a seven day supply is remaining.
  2. The Mount Cross medication cart contained a container of Bisacodyl 10MG suppositories as needed for constipation for resident 12; however, the medication expired on 06/30/2022 and also contained a bottle of Prednisone 10MG tablets for resident 3; however, the prescription was filled on 10/19/2022 and only contained 10 tablets for the resident to take within 5 days with a start date of 10/19/2022.
  3. The November 2022 medication administration record (MAR) for resident 4 indicates that the resident is to receive Neutrogena Hydro Boost body gel cream applied to both legs topically for dryness and keratosis daily at 8:00PM; however, from 11/02/2022 through 11/14/2022 the aforementioned cream has not been applied due to pharmacy action required. An interview with staff 1 confirmed that the cream was not available at the facility during on-site inspection.
  4. The Mount Cross medication cart contained an opened vial of Novolin insulin for resident 13 that did not contain the open date for the insulin. The manufacturer instructions for Novolin insulin states that the insulin is only good for 42 days once opened.
  5. The T-Bird medication cart contained an opened bottle of Latanoprost Sol eye drops for resident 2. The bottle did not contain a date that the medication was opened. Manufacturer instructions are to discard within 6 weeks of opening this medication.
  6. The T-Bird medication cart contained an opened Levemir insulin pen and a opened Novolog insulin pen for resident 10. The pens did not contain dates that they were opened. Manufacturer instructions are to discard Levemir insulin pens 42 days after opening and to discard Novolog insulin pens 28 days after opening.
  7. The T-Bird medication cart contained an opened Basaglar insulin pen and an opened Lantus Solostar insulin pen for resident 11. The insulin pens did not contain the date that they were open. Manufacturer instructions are to discard these insulin pens 28 days after opening.
  8. The control count sign sheet for the Mount Cross and the T-Bird medication carts were missing signatures for multiple shifts from 11/1/2022 through 11/15/2022. The facility medication management plan has documentation that “Both staff signatures and the count of bingo cards and sheets will be documented on either the schedule 2 count sheet provided by the communities preferred pharmacy and the communities controlled medication inventory sheet”.
Plan of correction
HWD/ED/Designee will conduct quarterly medication cart audits and remove medications that are expired and check to verify medications are available and labeled with open dates on insulins and eye drops. To assist with ongoing compliance the HWD/ED/Designee will audit medication carts weekly for four (4) weeks, to verify compliance and review substance count sheets when medication administration staff changes.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. The UAI (uniform assessment instrument) for resident 1, dated 11/01/2022, indicates that the resident requires mechanical help with transferring; however, this identified need is not indicated on the resident’s ISP dated 11/01/2022. Interview with staff 4 confirmed that the resident does require mechanical help with transferring.
  2. The UAI for resident 3, dated 12/01/2021, indicates that the resident requires mechanical help and supervision with bathing; however the ISP for the resident, dated 12/01/2021 is inconsistent as it indicates that the resident requires mechanical help and physical assistance with bathing. Interview with staff 4 revealed that the UAI is correct. The ISP for resident 3 also indicates that the resident is receiving physical and occupational therapy services and wears a right wrist splint due to a fracture; however, interview with staff 4 revealed that the resident no longer receives physical and occupational therapy services and no longer wears a right wrist splint.
  3. Interview with staff 5 revealed that the facility indicates on a resident’s ISP if they have an allergy. The record for resident 3 contains a signed physician’s order, dated 11/08/2022, that the resident has an allergy to Sulfa Antibiotics and this allergy is also included on the resident’s November 2022 medication administration record; however, the aforementioned allergy is not indicated on the resident’s ISP.
  4. The ISP for resident 6, dated 08/18/2022, indicates that the resident receives oxygen therapy two liters per minute as ordered by his physician; however, the ISP does not indicate what the oxygen source is.
  5. The record for resident 5 contained therapy progress notes which indicated that wound care therapy had started on 11/09/2022; however, the ISP for resident 5, dated 10/11/2022, was not updated to reflect this need. Also, the uniform assessment instrument for resident 5, dated 10/12/2022, states that the resident requires mechanical assistance for dressing, walking, and mobility; however, the ISP for resident 5, dated 10/11/2022, did not address these needs.
  6. The UAI dated 08/25/2022 in the record for resident 2 has documentation that the resident requires physical assistance with wheeling, transferring, bowel and bladder and is disoriented to some spheres some of the time with place and time being the spheres affected. Also the record for resident 2 has documentation that the resident uses a halo device on their bed. The ISP dated 07/12/2022 in the record for resident 2 does not address these identified needs.
Plan of correction
HWD/Designee will review resident ISP’s and update to reflect services being provided to resident. HWD/designee will review ISP’s during care plan meetings as well as during Collaborative Care Meetings held bi- monthly to verify the accuracy of the assessment. To assist with ongoing compliance the ED/designee will audit monthly for three (3) months to verify services on ISP.
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure for private pay individuals, the uniform assessment instrument (UAI) was completed as required.
Evidence
  1. The UAI for resident 3, dated 12/01/2021, did not contain documentation regarding if the resident does or does not require assistance with eating/feeding.
Plan of correction
HWD/designee will review current resident UAI’s and update as determined appropriate. HWD/designee will re-educate direct care staff who complete UAI’s on the Uniform Assessment Instrument. To assist with ongoing compliance the HWD/designee will review a random sample of resident UAI’s weekly for four (4) weeks
22VAC40-73-680-B
Based on observations of the facility medication carts, the facility failed to ensure that all medication remained in the pharmacy issued container with prescription label until administered to the resident.
Evidence
  1. A Lantus Solostar insulin pen was observed on the T-Bird cart without a pharmacy prescription label or resident name.
  2. 1 green and 2 white pills were observed lying loose in the bottom of the second drawer of the T-Bird medication cart.
  3. A yellow gel capsule was observed lying loose in the bottom of the second drawer of the Mount Cross medication cart.
Plan of correction
HWD/designee will re-educate staff administering medications regarding proper labeling of medications stored in the medication cart. To assist with ongoing compliance, the HWD/designee will audit medication carts weekly for four (4) weeks
22VAC40-73-610-B
Based on observation, the facility failed to ensure that the menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. While completing a tour of the physical plant on the date of inspection, collateral 2 observed that the posted weekly menu was from the week of October 9, 2022 – October 15, 2022, and the posted weekly snack menu was from July 3, 2022 – July 30, 2022.
Plan of correction
Dining Services Manager/Designee will check for compliance of menus for meals and snacks for the current week are posted in an area conspicuous to residents. To assist with ongoing compliance ED/Designee will review menus and snack postings to verify compliance, weekly for four (4) weeks.
22VAC40-73-320-A
Based on record review, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall contain all required components which include significant medical history, any diagnosis or significant problems, and a statement that specifies whether the individual is considered ambulatory or non-ambulatory.
Evidence
  1. The record for resident 9, admitted 01/31/2022, contained a “Physician/Healthcare Provider Plan of Care” physical examination form which indicated that the physician visit occurred on 08/05/2021 but was signed by a physician on 02/08/2022. This form did not indicate if the individual has any significant medical history, if there are any diagnoses or significant problems, or if the individual is considered ambulatory or non-ambulatory.
Plan of correction
The following is Brookdale Danville Piedmont, formerly known as Abingdon Place of Danville, Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated November 15, 2022. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. Executive Director (ED)/designee will re-educate staff responsible for reviewing admission paperwork for completeness of required information on the physicians plan of care. ED/designee will review new admissions to verify diagnoses and ambulatory status is indicated. To assist with ongoing compliance the ED/Health and Wellness Director (HWD)/designee will review the physician plan of care prior to admission weekly for four (4) weeks
22VAC40-73-680-M
Based on a medication cart audit, resident record review and staff interview, the facility failed to ensure medications ordered for as needed administration (PRN) were available at the facility.
Evidence
  1. The record for resident 3 contained a physician’s order, dated 11/08/2022, for Benzonate 200MG one capsule every 8 hours as needed for cough and Ondansetron 4MG one tablet every 6 hours as needed for nausea. Staff 1 revealed that the aforementioned PRN medications were not available at the facility during on-site inspection.
Plan of correction
HWD/ designee will re-educate registered medication aide staff on having prn medications available for use. To assist with ongoing compliance, the HWD/Designee will audit medication carts weekly for four (4) weeks
22VAC40-73-380-A
Based on resident record review, the facility failed to ensure prior to or at the time of admission, the required personal and social information for a resident was obtained.
Evidence
  1. The resident-personal social data document for resident 1 does not include document regarding the following: service in armed forces (if applicable), information on advance directives, DNR orders, or organ donations (if applicable), clergyman/place of worship (if applicable), next of kin (if known), and the address, phone number and cell phone number for the resident’s personal physician and person dentist.
  2. The record for resident 3 contains a signed physician’s order, dated 11/08/2022, that the resident has an allergy to Sulfa Antibiotics and this allergy is also included on the resident’s November 2022 medication administration record; however, the resident-personal social data document for the resident indicates that the resident has no allergies.
Plan of correction
ED/designee will re-educate staff responsible for assisting in the admission process information regarding personal and social information to be obtained for each resident. ED/designee will review new admission documentation to verify that the resident personal social data form is completed. To assist with ongoing compliance, the ED/designee will review personal social data form weekly for four (4) weeks.
22VAC40-73-650-E
Based on resident record reviews, the facility failed to ensure that physician orders were maintained in resident records.
Evidence
  1. A physician order dated 08/11/2022 to change the diet for resident 8 from a puree diet to a regular diet was not located in the record for resident 8 on the day of inspection.
Plan of correction
HWD/ED/Designee will review current resident diet orders for compliance with physicians orders. To assist with ongoing compliance, the HWD/ED/Designee will review diet orders weekly for four (4) weeks to verify
April 25, 2022Inspection8 violations
Inspection dates
04/25/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
The LI for Brookdale Danville Piedmont conducted a monitoring visit at the facility on 04/25/2022 in conjunction with another LI from 9:00am until 2:00pm and noted 48 residents to be in care. A tour of the facility physical plant was conducted and required posting were noted. The morning exercise activity and mid day meal were observed. The 11:00am medication pass was observed and the medication carts were audited. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. An exit interview was conducted with the facility Administrator on the day of inspection in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.
Violations
22VAC40-73-100-C-1
Based on an audit of the facility medication carts, the facility failed to ensure that blood glucose monitoring practices that are consistent with CDC recommendations were followed.
Evidence
  1. The Mount Cross medication cart contained a glucometer bag labeled for resident 10 on the cart but the meter inside the bag was not labeled with the residents name.
  2. The T-Bird medication cart contained glucometer bags labeled for residents 11 and 12 on the cart but the meters inside of the bags were not labeled with the residents name.
  3. The T-Bird medication cart contained a glucometer bag labeled for resident 5 on the cart but the meter inside of the bag was labeled for resident 12.
Plan of correction
The following is Brookdale Danville Piedmont, formerly known as Abingdon Place of Danville, Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated April 25, 2022. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. • Glucometer meters will be labeled with the resident name • HWD/Designee will audit carts to verify all glucometer meters are labeled with the residents name • To assist with compliance, the HWD/designee will audit carts weekly for 4 weeks to verify compliance
22VAC40-73-320-A
Based on a review of resident records, the facility failed to ensure that physical examinations were completed within 30 days preceding admission and contained all required information.
Evidence
  1. The record for resident 6, admitted on 02/08/2022, has documentation on the physical examination that the actual exam was conducted on 08/05/2021. The physical examination form was also incomplete as it did not contain information as to whether the resident was ambulatory or non-ambulatory.
Plan of correction
• ED/designee will re-educate HWD/Resident Care Coordinator/RMAs on documentation requirements regarding physical examination being conducted within 30 days of move in as well as ambulatory status must be noted on the physician’s plan of care. • To assist with compliance, weekly for four (4) weeks, the ED/HWD/Designee to review new admissions for completeness of the physicians plan of care.
22VAC40-73-450-E
Based on a review of resident records, the facility failed to ensure that individualized service plans (ISP) were signed by the resident or their legal representative.
Evidence
  1. The record for resident 3 has documentation that the residents ISP was updated on 12/07/2021 but the ISP has not been signed by the resident or their legal representative.
Plan of correction
• HWD/Designee will review ISP’s to verify signature by the resident or legal representative or document attempts to get the signature • To assist with compliance HWD/Designee will review ISP’s for signatures weekly times 4 weeks.
22VAC40-73-450-F
Based on a review of resident records, the facility failed to ensure that individualized service plans (ISP) were updated to reflect changes in a residents condition.
Evidence
  1. The record for resident 1 has documentation that the resident is receiving wound care services to the right heel from a Home Health Agency. The wound care and Home Health services are not documented on the residents ISP dated 01/24/2022.
Plan of correction
• HWD/Designee will review ISP’s to verify that all individualized services being received are noted on the ISP • To assist with compliance the HWD/Designee will audit ISP’s to verify weekly times 4 weeks.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to maintain the interior on good repair.
Evidence
  1. The second set of columns inside from the front door of the facility were noted to have cracked drywall around the columns at the ceiling.
Plan of correction
• Maintenance Director/ED/designee will have the columns inside of the front door of facility checked for safety and repair damaged drywall around the ceiling. • Maintenance Director will inspect building routinely for damages weekly time 4 weeks.
22VAC40-73-700-2
Based on observations of the facility physical plant, the facility failed to ensure “No Smoking-Oxygen in Use” signs were posted in any room where oxygen is in use.
Evidence
  1. Room 13, which belonged to resident 2, contained eight containers of oxygen; however, a “No Smoking-Oxygen in Use” sign was not posted in the room on the day of inspection.
Plan of correction
• HWD/Designee will verify that all residents with oxygen have the no smoking oxygen in use signs on doors. • HWD/Designee will audit all residents on oxygen rooms to verify signage is in place weekly times 4 weeks.
22VAC40-73-640-A
Based on a review of facility documentation, the facility failed to follow their procedures for methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The shift change sign sheet for counting controlled substances on the Mount Cross medication cart did not have staff signatures for the count at 3pm on 04/06/2022 and 11pm on 04/06/2022.
  2. The shift change sign sheet for counting controlled substances on the T-Bird medication cart did not have staff signatures for the count at 11pm on 04/02/2022 and 11pm on 04/16/2022.
Plan of correction
• HWD/ED/Designee will review accurate counts of controlled substance count sheets when medication administration staff changes. • To assist with compliance the HWD/ED/Designee will review controlled substance count sheets weekly times 4 weeks.
22VAC40-73-250-D
Based on a review of staff records, the facility failed to ensure that the results of a risk assessment documenting the absence of tuberculosis was submitted for each staff person on or within seven days prior to the first day of work at the facility.
Evidence
  1. The record for staff person 3, hired 03/21/2022, contained a TB screening chest x-ray report with a completion date of 02/04/2021.
Plan of correction
• Staff will be administered TB or have a TB screening to assess for risk of tuberculosis within seven days prior to the first day of work at the facility. • BOC/designee will assist with compliance of TB screenings prior to first day of work at the facility. • To assist with ongoing compliance/Executive Director (ED)/designee will audit new hires monthly for three (2) months to verify all associates are screened for TB within 7 days of starting at the facility
July 16, 2021Inspection1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 7/16/2021 and concluded on 7/22/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations can be found on the violation notice.
Violations
22VAC40-73-550-C
Based on a review of facility documentation and interviews with staff, the facility failed to ensure that resident rights were provided to residents.
Evidence
  1. A facility incident report dated 7/19/2021 has documentation that on 7/8/2021 staff person 2 was made aware of concerns in regards to resident 1. The concerns list that staff person 1 had been using her cell phone to voice record their interactions with resident 1 while in the residents room. It also has documentation that staff person 1 had made statements to resident 1 that she was going to get resident 1 kicked out of the facility. The incident report documents that during the investigation, staff person 1, who was suspended from employment pending the investigation, admitted to using a cell phone to voice record resident 1 as well as admitted to making comments about getting the resident 1 kicked out of the facility, of which both actions go against resident rights to be free from abuse or neglect.
Plan of correction
The following is Brookdale Danville Piedmont, formerly known as Abingdon Place of Danville, Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated July 23, 2021. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. ? ED/designee will re-educate staff on resident rights ? ED/designee will re-educate staff on resident abuse/neglect ? BOC/designee will verify resident rights and abuse/neglect training is documented in associate files upon hire and annually thereafter.
December 11, 2020Inspection3 violations
Inspection dates
Dec. 11, 2020
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 12/10/2020 and concluded on 12/14/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 50. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, employee schedules, fire and health department inspections, fire drill logs and dietician oversight of special diets submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-450-C
Based on a review of resident records, the facility failed to address all identified needs on individualized services plans (ISPs).
Evidence
  1. The record for resident 1 has a physician order signed 12/3/2020 for a No Added Salt diet. The ISP dated 6/5/2020 has documentation that the resident is on a regular diet and does not address the No Added Salt diet needs.
  2. The ISP dated 6/19/20 for resident 3 has documentation that the resident is receiving wound care services from a home health agency but does not address the facility responsibilities/measures in place for the residents wound care needs.
Plan of correction
The following is Brookdale Danville Piedmont, formerly known as Abingdon Place of Danville, Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated December 3, 2018. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. Resident ISP’s will be reviewed and updated by the Health and Wellness Director (HWD)/Nurse designee to reflect the resident’s needs and preferences, and include other supports that are involved in delivery of services. HWD/Designee will review and update all resident ISPs to reflect the residents? needs and services. To assist with compliance, the HWD/designee will review the resident’s ISPs during care plan meetings held with the resident and/or responsible party, as well as during Collaborative Care meetings held bi-monthly to verify the accuracy of the assessment, as well as the documentation to include all supports that are participating in delivery of services to the resident.
22VAC40-73-450-D
Based on a review of resident records, the facility failed to ensure that services provided by both the facility and hospice provider are included on the individualized service plan (ISP).
Evidence
  1. The ISP dated 6/5/2020 for resident 2 has documentation that the resident is receiving hospice services as ordered does not specify/detail what services are being provided by hospice to the resident.
Plan of correction
Resident #2 ISP will be reviewed and updated by the HWD/Nurse designee to reflect services being provided by the community and services provided by hospice. Health and Wellness Director/Designee will review and update all resident ISPs to include notes as to what services the resident is receiving and by the provider of the services. HWD/designee will review the resident’s ISPs during care plan meetings held with the resident and/or responsible party, as well as during Collaborative Care meetings held bi-monthly to verify the accuracy of the assessment, as well as the documentation to include all supports that are participating in delivery of services to the resident. To assist with ongoing compliance/Executive Director (ED)/designee will audit, monthly for three (3) months, the ISPs of all residents on hospice to verify all services are identified.
22VAC40-73-470-F
Based on a review of resident records, the facility failed to ensure that when a resident suffered an accident, injury or medical condition that the circumstances involved and the medical attention received was documented including the date and time of occurrence, as well as the personnel involved.
Evidence
  1. The record for resident 1 has documentation of the resident returning from the hospital on 9/29/2020. In an interview with staff person 4 it was noted that resident 1 went to the hospital due to a fall. The record for resident 1 does not have documentation of the circumstances involved and the medical attention received from resident 1's fall.
  2. The record for resident 2 has documentation of the resident returning from the emergency room on 11/25/20. In an interview with staff person 4 it was noted that resident 1 was sent to the emergency room due to changes in their medical condition. The record for resident 2 does not have documentation of the circumstances involved and the medical attention received when the change in medical condition occurred.
Plan of correction
ED/designee will re-educate HWD/Resident Care Coordinator/RMAs on documentation requirements. To assist with compliance, weekly for four (4) weeks, the ED/HWD/Designee to review documentation in Resident #2’s record.