15
Inspections
On record
7
With violations
Visits that cited something
8
Clean visits
Nothing cited
18
Violations cited
Individual findings
17
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint
Brookdale Roanoke was inspected 15 times between April 19, 2021 and March 12, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 18 violations under 17 distinct standards. 4 inspections were prompted by a complaint.
A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.
VDSS publishes inspections on a rolling window. 13 of these 15 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
05/31/2028
Administrator
Aaron Rice
Licensing inspector
Holly Copeland
Inspector phone
(540) 309-5982
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit
Inspection History
15Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
March 12, 2026Inspection
Inspection dates
03/12/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
08:15 AM to 02:00 PM
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: 50
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: N/A
Number of interviews conducted with staff: 2
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-450-D
Based on record review and staff interview, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident, and the services provided by each shall be included on the individualized service plan (ISP).
Evidence
- The record for resident 3 contained documentation that the resident has been receiving hospice services from collateral 1 since 10/29/2025.
- The most current hospice plan of care for resident 3 contained orders from 02/25/2026 for: Home health aide (HHA) 2x per week for 1 week starting on 02/23/2026 (week 5) and 2x per week for 8 weeks starting on 03/01/2026 (week 6).
- The current hospice plan of care for resident 3 also contained orders from 03/02/2026 for: Social worker (MSW) 1x per month for 2 months starting on 03/02/2026 (week 6) and MSW (PRN) 5 visits starting 01/27/2026 (week 1). Reason for PRN: Change in condition/pt needs.
- The ISP for resident 3, dated 11/30/2025, did indicate that resident 3 has been receiving hospice services from collateral 1 since 10/30/2025; however, the ISP did not contain documentation of the services that will be provided by the hospice staff and how often, per the hospice plan of care.
- An interview with staff 4 and staff 5 was unsuccessful at locating an ISP for resident 3 where this information is documented.
Plan of correction
Not published by VDSS.
October 21, 2025Inspection
Inspection dates
10/21/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
10/21/2025 from 11:30 AM to 12:30 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-report was received by VDSS Division of Licensing on 10/14/2025 regarding allegations in the area(s) of:
22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES
22VAC40-73-(10) 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: 55
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: N/A
Number of interviews conducted with residents: N/A
Number of interviews conducted with staff: 2
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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 Holly Copeland, Licensing Inspector, at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 12, 2025Inspection
Inspection dates
03/12/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
03/12/2025 from 08:30 AM to 01:45 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Holly Copeland, Licensing Inspector 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Complaint survey
Inspection dates
01/15/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 61316
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
01/15/2025 from 11:45 AM to 12:45 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 01/10/2025 regarding allegations in the area(s) of:
Resident care and related services;
Additional requirements for facilities that care for residents with serious cognitive impairments.
Number of residents present at the facility at the beginning of the inspection: 52
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 0
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Complaint survey
Inspection dates
01/15/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 61315
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
01/15/2025 from11:45 AM to 12:45 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 01/10/2025 regarding allegations in the area(s) of:
Resident care and related services;
Additional requirements for facilities that care for residents with serious cognitive impairments.
Number of residents present at the facility at the beginning of the inspection: 52
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 0
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
July 30, 2024Complaint survey
Inspection dates
07/30/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint 60059
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
07/30/2024 from 01:30 PM to 02:00 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 07/08/2024 regarding allegations in the area(s) of:
Resident care and related services; Resident accommodations and related provisions.
Number of residents present at the facility at the beginning of the inspection: 55
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
June 28, 2024Inspection
Inspection dates
06/28/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
06/28/2024 from 01:45 PM until 02:15 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 06/18/2024 regarding allegations in the area(s) of: Resident care and related services.
Number of residents present at the facility at the beginning of the inspection: 55
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: N/A
Number of interviews conducted with staff: 1
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Holly Copeland, Licensing Inspector at (540)-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-200-B
Based on record review and staff interview, the facility failed to ensure that direct care staff who are responsible for caring for residents with special healthcare needs shall only provide services within the scope of their practice and training.
Evidence
- The Virginia Department of Social Services Standards for Assisted Living Facilities, last revised 10/13/2021, defines a licensed healthcare professional as “any health care professional currently licensed by the Commonwealth of Virginia to practice within the scope of his profession, such as a nurse practitioner, registered nurse, licensed practical nurse, clinical social worker, dentist, occupational therapist, pharmacist, physical therapist, physician, physician assistant, psychologist, and speech-language pathologist”.
- According to the License Lookup webpage through the Virginia Department of Health Professions, staff 1 is registered to provide medications in an assisted living facility; however, staff 1’s position is not defined as a licensed healthcare professional.
- The facility’s direct care staff flowsheet for witnessed, unwitnessed, or suspected falls with head injury indicates that for falls with no apparent injury or minor injury (small laceration, bump, or bruise), the Health and Wellness Director/Nurse Designee (RN, LPN, LVN) is to be notified to evaluate and/or direct next the step.
- The facility’s incident report indicates that at around 05:45 AM on 06/14/2024, resident 1 appeared to have had a fall that was unwitnessed. Per the facility report, resident 1 appeared to have slipped in urine in his room and after being assessed, resident 1 had a small hematoma to the back of his head as well as a superficial abrasion to the left upper arm and elbow but was otherwise ok. Per the facility report, resident 1 was not sent out for evaluation, which is inconsistent with the facility’s fall protocol. The facility report also states that the family of resident 1 was not notified at the time of the fall.
- On 06/28/2024, during LI’s on-site follow up, staff 2 stated to LI that part of the facility’s internal investigation of the incident consisted of an interview with staff 1 who disclosed that, even though she is not a nurse or other licensed healthcare professional, she assessed resident 1 upon discovering him after a suspected unwitnessed fall. Despite having a small hematoma to the back of his head as well as a superficial abrasion to the left upper arm and elbow, staff 1 decided not to seek medical evaluation nor did she contact the facility’s Health and Wellness Director or other licensed healthcare professional to seek guidance on whether resident 1 should receive medical attention, as is instructed to do in the direct care staff flowsheet for resident falls.
Plan of correction
· Executive Director and/or Health and Wellness Director provided re-training on 7/1/2024 to all LPNs and Med Techs that run charge on responding to resident falls and head injuries, including requirements of communication and reporting.
· Executive Director and/or Health and Wellness Director issued a corrective action to the direct care staff which was determined to have provided a service outside the scope of their practice.
· To assist with ongoing compliance, the ED or designee will complete a weekly audit for one month of all documented resident falls from within the past 7 days to verify that the facility’s fall protocol was followed.
22VAC40-73-460-F
Based on record review and staff interview, the facility failed to ensure that a resident’s next of kin, legal representative, or designated contact person is notified of a resident falling within 24 hours of the initial discovery or knowledge of the incident.
Evidence
- The facility’s incident report indicates that around 05:45 AM on 06/14/2024, resident 1 appeared to have had a fall that was unwitnessed. Per the facility report, resident 1 appeared to have slipped in urine in his room and after being assessed, resident 1 had a small hematoma to the back of his head as well as a superficial abrasion to the left upper arm and elbow but was otherwise ok.
- The facility’s incident report indicates that staff 1 did not notify resident 1’s family at the time of the fall. The facility report, and the interview of staff 2 revealed to LI that due to the time of morning, staff 1 had assumed that the oncoming 7 AM – 3 PM charge staff member in that unit would notify the family of resident 1; however, staff 1 did not inform that oncoming staff member at shift change that this task still needed to be completed. As a result, the resident’s family was not notified that he had fallen earlier that morning.
- In a separate interview, staff 3 revealed to LI that resident 1’s family only learned of the fall when they came to visit at the facility during the late morning on 06/15/2024. Once the family observed the abrasion to his elbow, they asked the direct care staff on duty how it occurred. It was at that time that the family learned of the unwitnessed fall that occurred the morning before, and the family decided to take resident 1 to the hospital for evaluation where he was diagnosed with a minor head injury.
Plan of correction
· Executive Director and/or Health and Wellness Director provided re-training on 7/1/2024 to all LPNs and Med Techs that run charge on responding to resident falls and head injuries, including requirements of communication and reporting.
· Executive Director and/or Health and Wellness Director issued a corrective action to the direct care staff which was determined to have failed to notify the resident’s designated contact person.
· To assist with ongoing compliance, the ED or designee will complete a weekly audit for one month of all documented resident falls from within the past 7 days to verify that notification was made to the resident’s next of kin, legal representative, or designated contact person within 24 hours of initial discovery or knowledge of the incident.
April 2, 2024Inspection
Inspection dates
04/02/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
04/02/2024 from 08:45 AM until 04:15 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-120-C
Based on record review and staff interview, the facility failed to ensure that all new staff shall be trained in the relevant laws, regulations, and the facility’s policies and procedures sufficiently to implement emergency and disaster plans for the facility; procedures for the handling of resident emergencies; use of the first aid kit and knowledge of its location; handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures; procedures for reporting and documenting incidents; methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and the needs, preferences, and routines of the residents for whom they will provide care.
Evidence
- The form RECORD OF INITIAL STAFF TRAINING for staff 1 indicated that staff 1’s first day of work was 08/14/2023; however, the form was incomplete to show that staff 1 had received training the following areas: Use of the first aid kit and knowledge of its location; handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures; procedures for reporting and documenting incidents; methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and the needs, preferences, and routines of the residents for whom they will provide care.
- Interview with staff 5 revealed that there is no other documentation which verifies that staff 1 had received initial training in those areas which were incomplete.
- The form RECORD OF INITIAL STAFF TRAINING for staff 2 indicated that staff 2’s first day of work was 10/05/2023; however, the form was incomplete to show that staff 2 had received training the following areas: Emergency and disaster plans for the facility; Procedures for the handling of resident emergencies; use of the first aid kit and knowledge of its location; handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures; procedures for reporting and documenting incidents; methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and the needs, preferences, and routines of the residents for whom they will provide care.
- Interview with staff 5 revealed that there is no other documentation which verifies that staff 2 had received initial training in those areas which were incomplete.
Plan of correction
Not published by VDSS.
July 11, 2023Inspection
Inspection dates
07/11/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring - Self-reported incident
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
07/11/2023 from 01:30 PM until 03:00 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 06/22/2023 regarding allegations in the area(s) of:
Provision of resident care and related services.
Number of residents present at the facility at the beginning of the inspection: 49
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: N/A
Number of interviews conducted with staff: 1
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Resident care and resident rights violation.
A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-550-C
Based on record review and staff interview, the facility failed to ensure that a resident of an assisted living facility has the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia and assisted living facility regulations, including ensuring that a resident’s known needs are not neglected or ignored by personnel of the facility and is treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity.
Evidence
- On the evening of 06/22/2023, LI received a self-report from staff 2 about a staff to resident incident. The report alleged that resident 1 had called for assistance while toileting between 03:00 AM and 03:30 AM on 06/22/2023. The report further alleged that staff 1 responded to the request for assistance but refused to assist resident 1. Then, staff 1 was reported to have pushed resident 1 and threw a plastic fork at him. The report added that there was no injury to resident 1 and that staff 2 was suspended pending an investigation.
- During the on-site incident follow up on 07/11/2023, staff 2 revealed to LI that during their investigation, staff 1 did not confirm that an assault had occurred; however, staff 1 did admit that she felt uncomfortable helping resident 1 that morning, so staff 1 distanced herself from resident 1, left the room, and asked staff 3 to assist him with toileting instead, so staff 3 provided him assistance.
- Further interview with staff 2 revealed that staff 3 did provide assistance to resident 1 at the time of the incident, and staff 1 is no longer employed at the facility.
Plan of correction
• Brookdale Roanoke, VA respectfully disagrees with citation as immediate actions were taken, the resident was unharmed, and care was provided.
• Executive Director and/or Health and Wellness Director made self-reports to APS, VDSS, Doctor and Family within appropriate time period for reporting.
• Executive Director and/or Health and Wellness Director noted associate had previously received training on dementia care, approach, UADC, and resident rights.
• Executive Director, Health and Wellness Director and/or Charge nurse suspended the associate and the associate was subsequently terminated.
• Executive Director (ED)/Health and Wellness Director (HWD)/Resident Care Coordinator (RCC) or designee will provide re-training to staff on Resident Rights by August 30, 2023.
April 11, 2023Inspection
Inspection dates
04/11/2023
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 IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
04/11/2023 from 08:55 AM until 03:00 PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observation during a tour of the building, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
- At approximately 9:21AM during on-site inspection, collateral 1 (LI) noted a container of Super Sani-cloth germicidal disposable wipes and a spray bottle of 14 Antibacterial All-Purpose Cleaner located in the unlocked cabinet above the small sink in the Cottage kitchen. Both items contained a warning to keep out of reach of children.
Plan of correction
• The items noted have been removed from the unlocked cabinet in the Cottage kitchen.
• Executive Director (ED)/Health and Wellness Coordinator (HWC)/Resident Care Coordinator (RCC)/Maintenance Manager (MM)/Sales Manager (SM) or designee will complete an audit of all 4 neighborhoods and all 56 resident rooms to verify that cleaning supplies and other hazardous materials are stored in a locked area. The ED will be responsible for directing additional corrective action based on audit findings.
• HWC/RCC/ED or designee will provide re-training to staff on appropriate storage of cleaning supplies and hazardous materials.
22VAC40-73-870-A
Based on observation during a tour of the building, the facility failed to ensure that the interior of the building was maintained in good repair, kept clean and free of rubbish.
Evidence
- The flooring in front of the dresser in room 35 contained a large area of a dark staining. Also, collateral 1 (LI) noted a quarter sized hole in the flooring beside the end of bed in room 35.
- It was noted by collateral 1 that the carpet in the back corner beside the window in the Cottage living room contained a large area of staining. The carpet in the Cottage living room contained small pieces of debris along the baseboards, mainly behind the furniture. The baseboards in the Cottage dining room contained areas of peeling and chipping white paint. Also, in the Cottage dining room, the wall by a table that is pushed up against the wall appeared that something had been spilled down the wall.
- The baseboards in the Country dining room contained areas of peeling and chipping white paint
Plan of correction
• The flooring in room 35 will be replaced by the Maintenance Manager or designee.
• The carpet in the Cottage living room will be vacuumed and cleaned by the Maintenance Manager or designee.
• The baseboards in the Cottage dining room will be painted and the walls in the Cottage dining room will be cleaned by the Maintenance Manager or designee.
• The baseboards in the Country dining room will be painted by the Maintenance Manager or designee.
22VAC40-73-250-D
Based on staff record review and staff interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
- d by the completion of the current screening form published by the Virginia Department of Health (VDH) or a form consistent with it. EVIDENCE:
- The record for staff 2, date of hire 08/30/2022, contained a VDH TB risk assessment form for staff 2; however, the document did not contain a date of when the risk assessment was completed.
- Interview with staff 6 confirmed this was accurate and there was no other TB risk assessment document for staff 2 to indicate this was done on or within seven days prior to staff 2’s first day of work.
Plan of correction
• A new TB risk assessment form will be completed for Staff 2.
• BOM/ED or designee will complete an audit of all staff charts to verify that all TB risk assessments are complete.