Virginia DSS · Assisted Living Facility

Brookdale Virginia Beach

📍 937 Diamond Springs Road, Virginia Beach, VA, 23455

ID 36812One Year licenseActive
28
Inspections
On record
25
With violations
Visits that cited something
3
Clean visits
Nothing cited
94
Violations cited
Individual findings
49
Standards cited
Distinct rules
16
Complaint visits
Prompted by a complaint

Brookdale Virginia Beach was inspected 28 times between September 30, 2020 and November 14, 2025 by the Virginia Department of Social Services. 25 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 94 violations under 49 distinct standards. 16 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. 23 of these 28 are still on the state's site; the other 5 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
11/17/2026
Administrator
Leslie Rowe
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

28

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

November 14, 2025Inspection0 violations
Inspection dates
11/14/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/14/2025 from 2:00 pm to 3:15 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 11/12/25 and 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: 31 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:1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: none 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. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 21, 2025Inspection4 violations
Inspection dates
10/21/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-320
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025 from 9:30 am to 5:00pm. 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: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Water temperature checked, First Aid kit review and Emergency Preparedness reviewed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on the record review the facility did not ensure to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. Resident #1 has an ISP dated 7/14/2025 that was not signed by the resident’s POA.
  2. Resident #2 has an ISP dated 7/28/2025 that was not signed by the resident’s POA.
  3. Resident #3 has an ISP dated 7/10/2025 that was not signed by the resident’s POA.
  4. Staff #6 reviewed the ISP, and confirmed the plan was not signed by the resident’s POA.
Plan of correction
• Unable to retroactively correct POA signature on ISPs for Resident #1, Resident #2, and Resident #3. • The Health and Wellness Director or designee will send the ISPs for Resident #1, #2, and #3 to their legal representative within thirty (30) days for signature. • By 11/15/2025, Executive Director or designee will re-educate Health and Wellness Director on auditing Resident ISP due dates on a monthly basis to verify compliance. • To assist with ongoing compliance, Health and Wellness Director, Executive Director, or designee will review 5% of Resident charts for the Resident’s ISPs weekly, for four (4) weeks.
22VAC40-73-250-D
Based on the review of facility records and staff interviews, the facility did not ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as
Evidence
  1. The record for staff #2, hire date 09/12/2023, did not contain an annual risk assessment for TB. The staff record contains a risk assessment for TB completed on 12/21/2023.
  2. During an interview with staff #6 on 10/21/2025, the facility did not provide documentation of a completed annual TB risk assessment for staff #2.
Plan of correction
• Unable to retroactively correct annual TB screening for staff member #2 from start date. • Staff member #2 will be sent to Patient First for TB screening within thirty (30) days. • By 11/15/2025, Executive Director or designee will re-educate Business Office Manager on auditing associate TB due dates on a monthly basis to verify compliance • To assist with ongoing compliance, Business Office Manager, Executive Director, or designee will review 5% of associate files for the associate’s TB tests, weekly, for four (4) weeks
22VAC40-73-550-G
Based on the record review the facility did not ensure that the rights and responsibilities of residents with the resident or legal representative annually.
Evidence
  1. Resident #3, had a review of residents right on file dated 1/4/2023. The record did not contain a annual Resident Right review on file within the last year.
  2. Staff #6 reviewed the ISP, and confirmed the record did not contain the annual Resident’s Rights.
Plan of correction
• Unable to retroactively correct legal representative signature on Resident’s Rights for Resident #3. • Resident Rights for Resident #3 will be will be sent to legal representative within thirty (30) days for signature. • By 11/15/2025, Executive Director or designee will reeducate Health and Wellness Director on auditing Resident’s Resident Rights due dates on a monthly basis to verify compliance • To assist with ongoing compliance, Health and Wellness Director, Executive Director, or designee will review 5% of Resident charts for the Residents Rights documentation, weekly, for four (4) weeks
22VAC40-73-1140-B
Based on the record review the facility did not ensure that within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment.
Evidence
  1. Staff #1, DOH 10/16/2024, training log did not reflect 10 total hours of training in cognitive impairment during the onsite inspection on 10/21/2025.
  2. Staff #2 DOH 9/12/2023, training log did not reflect 10 total hours of training in cognitive impairment during the onsite inspection on 10/21/2025.
  3. Staff #3 DOH 3/17/2025, training log did not reflect 10 total hours of training in cognitive impairment during the onsite inspection on 10/21/2025.
Plan of correction
• Unable to retroactively correct 10 hours of Cognitive Impairment training for staff member #1, #2, and #3 from start date. • Staff member #1, #2, and #3 will complete the 10 hours of Cognitive Impairment training within thirty (30) days. • By 11/15/2025, Executive Director or designee will re-educate Business Office Manager, on the associate requirement to complete ten (10) hours of cognitive impairment training within the first 4 months of the associates start date. • To assist with ongoing compliance, Business Office Manager, Executive Director, or designee will review 5% of associate charts to confirm the associate’s 10 hours of Cognitive Impairment weekly for four (4) weeks.
May 21, 2025Complaint survey2 violations
Inspection dates
05/21/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/21/25 from 12:40 pm to 13:45 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 5/8/25 and 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: 24 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: 1 Additional Comments/Discussion: none The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on a review of the medication administration records and interview, it was determined that the facility did not ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. A review of the record for resident #1 shows that staff did not complete rounds every two hours on 5/8/25 between the hours of 12:00 am to 6:00 am. No signatures were noted on the round logs.
  2. Staff #1 acknowledges the round logs were not signed every two hours on 5/8/25 between 12:00 am and 6:00 am.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/4/2025. 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 improvements to satisfy that objective. 22VAC40-73-930. Provisions for signaling and call systems. • Community is unable to retroactively correct round log for Resident 1. • Executive Director or designee will retrain the direct care clinical staff members regarding the state requirement to complete two hour rounds and document in the rounding logs on all residents. • The Executive Director, Health and Wellness Director or Designee will conduct an audit of 5% of current resident records to verify the completion and ongoing accuracy of rounding logs by 8/11/2025.
22VAC40-73-530-C
Based on a review of an APS report and staff interview, it was determined that the facility did not ensure that the facility shall provide freedom of movement for the residents to common areas and to their personal spaces. The facility shall not lock residents out of or inside their rooms.
Evidence
  1. The APS report received on 05/08/2025, the resident was blocked from leaving her bedroom by staff #2 holding the door shut.
  2. Staff #1 conducted an internal investigation and confirms the resident was prevented from leaving her bedroom.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/4/2025. 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 improvements to satisfy that objective. 22VAC40-73-530.C Freedom of Movement • Implicated Staff Member #2 was investigated and is no longer with the organization • Executive Director or designee has retrained and in-serviced all direct care clinical staff members on the definition and the use of restraints, as well as abuse and neglect.
February 28, 2025Complaint survey4 violations
Inspection dates
02/28/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/28/25 from 9:40 am to 11:15 am. 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 1/7/25 and 2/20/25 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: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: 1 Additional Comments/Discussion: none The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on the record review the facility did not ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. The record for resident #2 contains a progress note documenting the resident experienced a fall on 2/26/25. Resident #2’s record contain a fall risk rating dated 1/8/25 and was not updated after the resident’s fall that occurred on 2/26/25.
  2. Staff #1 reviewed Risk Rating and confirms the Rating was not updated to reflect the most current fall.
Plan of correction
• The Executive Director or designee will correct record for resident number two. • The Executive Director or designee will retrain the direct clinical staff on fall risk prevention procedures, interventions, and safety ratings post fall. • The Executive Director or designee will audit 5% of the current resident records for compliance by 6/10/2025. • To assist with ongoing compliance the Executive Director or designee will conduct reviews of all current resident records for fall risk ratings monthly for two months.
22VAC40-73-450-E
Based on the record review the facility did not ensure to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. Resident #3 has an ISP that was not signed by the Administrator or designee, nor was the plan signed by the resident’s POA.
  2. Staff #1 reviewed the ISP, and acknowledge the plan was not signed.
Plan of correction
• The Executive Director or designee cannot retroactively correct Individualized Service Plan on Resident number 3 as the resident no longer resides at the community. • The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators and any ISP certified associates on Individualized Service Plans. • The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit of 5% of current resident ISP records by 6/10/2025. • To assist with ongoing compliance, the Executive Director, Health and Wellness Director, and Health and Wellness Coordinator or Designee will audit all current resident Individual Service Plans monthly for two months. Individual Service Plans will be updated for residents during admission, annually, and for significant changes in condition.
22VAC40-73-680-H
Based on a review of the medication administration records and interview, it was determined that the facility did not ensure that that the medication administration record (MAR) includes if the medication was administered or there was an omission.
Evidence
  1. The MAR for Risperidone 0.5mg tab did not indicate whether the medication was administered, or it was not administered on 2/21/2025. Documentation did not indicate an error or refusal.
  2. Staff #1 reviewed MAR and acknowledged the signature was missing.
Plan of correction
• The Executive Director, Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator or designee will retrain direct clinical staff on proper medication administration and charting procedures. • To assist with on-going compliance, the Executive Director, Health and Wellness Director and Health and Wellness Coordinator or designee will audit 5% of current resident records for medication administration monthly for two (2) months.
22VAC40-73-930-D
Based on a review of the medication administration records and interview, it was determined that the facility did not ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. A review of the MAR for resident #1 shows that staff did not complete rounds every two hours on 2/21/25 between the hours of 12:00 am to 6:00 am. No signatures were noted on the round logs.
  2. Staff #1 reviewed the document and acknowledges the MAR was not signed every two hours on 2/21/25 between 12:00 am and 6:00 am.
Plan of correction
• The Executive Director or designee will retrain the direct clinical staff on two rounding procedures and appropriate documentation on such. • The Executive Director or designee will audit 5% of the current resident records for compliance by 6/10/2025. • To assist with ongoing compliance the Executive Director or designee will conduct reviews of all current resident records for rounding compliance for two months.
December 12, 2024Complaint survey1 violation
Inspection dates
12/12/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/12/24 from 1:00 pm to 2:20pm. 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 12/2/24 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: 33 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:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: 1 Additional Comments/Discussion: none 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on the record review the facility did not ensure to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. The record for resident #1 contains a control count sheet for Morphine 15mg tab rx#14612367 missing staff signatures for control counts on the following shifts: 11/27/24 (7am-3pm), 11/28/24 (11pm-7am),12/2/24 (3pm-11pm), (11pm-7am), 12/3/24 (7am-3pm), (3pm-11pm), (11pm-7am).
  2. Staff #2 confirmed the record for resident #1 and acknowledged the Controlled Medication Count Records were incomplete.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 12/26/2024. 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. 22VAC40-73-640-A-8 Medication Management Plan and Reference Materials • The Executive Director, Health Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator or designee will retrain medication pass associates on auditing the medication carts and shift-change protocols related to medication counts. • To assist with ongoing compliance, the Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will perform audits on medication carts and count logs monthly for 2 months. Compliance date: 02/26/2025
November 25, 2024Complaint survey2 violations
Inspection dates
11/25/2024
Areas reviewed
None22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/24 from 1:10 pm to 3:30pm. 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 11/7/24 regarding allegations in the area(s) of: Staffing And Supervision, Resident Care And Related Services, Buildings and Grounds 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: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: 1 Additional Comments/Discussion: Buildings and Grounds An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care And Related Services A violation notice was issued; any violations not related to the complaints 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on observation and a review of the facility’s Medication Administration Record, it was determined that the facility did not ensure that the MAR shall include Any medication errors or omissions.
Evidence
  1. During the Medication Administration Record review for Resident #1, on 11/21/24 the following medications were not signed for: Melatonin 3mg(8:00pm), Trazadone 50mg(8:00pm), Seroquel 50mg(8:00pm), Zoloft 50mg(8:00pm)
  2. During the Medication Administration Record review for Resident #2, on 11/21/24 the following medications were not signed for: Atorvastatin 20mg(8:00pm) Trazadone 150mg(8:00pm), Risperidone 0.5mg(8:00pm), Safety checks for 2000, 2200 not documented on 11/21/24.
  3. Staff #2 confirmed the medication for resident #1 and Resident #2 were not signed by the staff administering medications.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/25/2024 but received on 12/02/2024. 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. 22VAC40-73-680-I. 11 Administration of Medications and Related Provisions • Unable to retroactively correct previous medication administration signatures within the ordered period for residents 1 and 2 for date 11/21/2024. • The Executive Director or designee will provide re-education to LPN’s and RMA’s on medication administration and the need for medications to be signed for within the ordered time frame that said medication is due by 12/13/2024. • To assist with on-going compliance, The Executive Director or designee will conduct weekly audits for medication administration signatures for 4 weeks and then monthly for two months. Compliance Date: 02/28/2025
22VAC40-73-325-B
Based on the record review the facility did not ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. The record for resident #1 contains a progress note documenting the resident experienced a fall on 11/10/24. Resident #1’s record contain a fall risk rating dated 8/28/24 and was not updated after the resident’s fall that occurred on 11/10/24.
  2. Staff #1 confirmed the record for resident #1 did not contain documentation of a fall risk rating completed after 11/10/24.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/25/2024 but received on 12/02/2024. 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. 22VAC40-73-325-B Fall Risk Rating • Unable to retroactively correct Fall Risk ratings for resident number 1 for 11/10/2024. • The Executive Director or designee will update the Fall Risk ratings for resident number 1 no later than 12/11/2024. • The Executive Director or designee will provide re-education to the licensed nurses and RMA’s on Fall Risk rating updates no later than 12/11/2024. • To assist with going compliance, the Executive Director or designee will randomly audit 5 % of current residents with falls for updated Fall Risk ratings once a month for two months. Compliance by 02/11/2025
November 6, 2024Inspection0 violations
Inspection dates
11/06/2024
Areas reviewed
22VAC40-73 PERSONNEL
Comments
Type of inspection: Monitoring An unannounced monitoring inspection took place on 11/06/24 at 2:20 pm until 2:33 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 10/30/24 regarding allegations in the area of: Personnel Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: none Additional Comments/Discussion: None 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. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 8, 2024Complaint survey3 violations
Inspection dates
10/08/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Buildings and Grounds
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/8/24/24 from 8:30 am to 4:30pm. 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 9/6/24 and 9/9/24 regarding allegations in the area(s) of: Personnel, Staffing And Supervision, Resident Care And Related Services, 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: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 3 Observations by licensing inspector: 3 Additional Comments/Discussion: Buildings and Grounds An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care And Related Services A violation notice was issued; any violations not related to the complaints 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-410-A
Based on the record review the facility did not ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident’s record.
Evidence
  1. The record for resident #1, admission date 6/20/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian.
  2. Staff #1 confirmed the record for resident #1 did not contain documentation of orientation to the facility.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-410-A Orientation and related information for residents ¿ Facility does not have the ability to retroactively correct signed orientation for resident number one as resident is no longer at the community. ¿ The Executive Director or designee will retrain Sales Manager and Clinical Staff on providing orientation documents upon admission to the facility by 12/1/24. ¿ The Executive Director, Business Office Manager, or designee will audit 5% of the current resident population to verify completion of orientation documentation in the resident’s records with signatures by 12/1/24. ¿ To assist with ongoing compliance the Executive Director, Business Office Manager, or designee will conduct reviews of current residents monthly for two months.
22VAC40-73-440-A
Based on the record review the facility did not ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission.
Evidence
  1. The record for resident #1, admission date of 9/23/24, did not contain a UAI completed prior to admission. The UAI in the record is dated 9/24/24.
  2. The record for resident #2, admission date of 6/20/24, did not contain a UAI.
  3. Staff #4 confirmed the record for resident #1 and resident #2 did not contain a UAI.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-440-A Uniform Assessment Instrument ¿ Facility does not have the ability to retroactively correct Uniform Assessment Instrument as resident number one (deceased) and resident number two (discharged) are no longer residing in the facility. ¿ The Executive Director or designee will retrain Sales Manager and Clinical Staff regarding the requirement for a Uniform Assessment Instrument completion prior to admission. ¿ The Executive Director or designee will audit 5% of the current resident population for completed Uniform Assessment Instruments by 12/1/2024. ¿ To assist with ongoing compliance the Executive Director or designee will conduct reviews of all new resident records monthly for two months.
22VAC40-73-325-B
Based on the record review the facility did not ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. The record for resident #5 contains a progress note dated 9/26/24 and an emergency room visit note dated 9/26/24 documenting the resident experienced a fall on 9/26/24. Resident’s #5 record did not contain a fall risk rating after the resident’s fall that occurred on 9/26/24.
  2. Staff #1 confirmed the record for resident #5 did not contain documentation of a fall risk rating completed after 9/26/24.
  3. The record for resident #1 contains progress notes that documents on the following dates the resident experienced a fall: 6/23/24, 6/26/24, 7/02/24, 07/08/24, 07/09/24. Resident’s #1 record did not contain documentation of a fall risk rating completed after each fall.
  4. Staff #1 confirmed the record for resident #1 did not contain documentation of a fall risk rating completed after the following dates: 6/23/24, 6/26/24, 7/02/24, 07/08/24, 07/09/24.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-325-B Fall Risk Rating ¿ Facility cannot retroactively correct record for resident number one, who is no longer a resident of the community. The Executive Director or designee will correct record for resident number five. ¿ The Executive Director or designee will retrain the direct clinical staff on fall risk prevention procedures, interventions, and safety ratings post fall. ¿ The Executive Director or designee will audit 5% of the current resident records for compliance by 12/1/2024. ¿ To assist with ongoing compliance the Executive Director or designee will conduct reviews of all current resident records for fall risk ratings monthly for two months.
October 8, 2024Inspection11 violations
Inspection dates
10/08/2024
Areas reviewed
22VAC40-73 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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/8/24/24 from 8:30 am to 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: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 3 Observations by licensing inspector: 3 Additional Comments/Discussion: Buildings and Grounds 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. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-410-A
Based on the record review the facility did not ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident’s record.
Evidence
  1. The record for resident #2, admission date 6/17/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian.
  2. The record for resident #4, admission date 10/07/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian.
  3. The record for resident #5, admission date 6/20/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-410-A Orientation and related information for residents ¿ Facility does not have the ability to retroactively correct signed orientation for resident number one as resident is no longer at the community. ¿ The Executive Director or designee will retrain Sales Manager and Clinical Staff on providing orientation documents upon admission to the facility by 12/1/24. ¿ The Executive Director, Business Office Manager, or designee will audit 5% of the current resident population to verify completion of orientation documentation in the resident’s records with signatures by 12/1/24. ¿ To assist with ongoing compliance the Executive Director, Business Office Manager, or designee will conduct reviews of current residents monthly for two months
22VAC40-73-450-E
Based on the record review the facility did not ensure the ISP shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. The record for resident #3 contains an ISP that includes an initiated date of 9/26/24 and 9/27/24 however the ISP does not include the date the ISP was signed by the licensee, administrator, or his designee. The resident’s ISP did not include the signature of the resident or the legal guardian.
  2. Resident’s #5 ISP dated 6/20/24 and 07/09/24 was not signed and dated by the resident or the legal guardian.
  3. Resident’s #4 ISP dated 10/07/24 was not signed by the licensee, administrator, or designee and the resident or legal guardian.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-450-E Individualized Service Plans ¿ Facility unable to retroactively correct Individualized Service Plan on Resident number 3 and Resident number 5 as residents are no longer at the community. ¿ The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators and any ISP certified associates on Individualized Service Plans. ¿ The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit of 5% of current resident ISP records by 1/1/2025. ¿ To assist with ongoing compliance, the Executive Director, Health and Wellness Director, and Health and Wellness Coordinator or Designee will audit all current resident Individual Service Plans monthly for two months. Individual Service Plans will be updated for residents during admission, annually, and for significant changes in condition.
22VAC40-73-1090-A
Based on the record review the facility did not ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. The record for resident #5, admission date of 6/20/24, did not contain an assessment for serious cognitive impairment.
  2. Staff #1 confirmed the record for resident #5 did not contain an assessment for serious cognitive impairment.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-1090-A Assessment ¿ Facility does not have the ability to retroactively correct missing cognitive impairment assessment on resident number 5 as they are no longer residing at the community. ¿ The Executive Director or designee will retrain the Sales Manager and the direct care clinical staff regarding the requirements to have the cognitive impairment assessment and other forms completed upon admission. ¿ The Executive Director, and Sales Manager, or designee will audit 5% of current resident files for compliance by 12/1/2024. ¿ To assist with ongoing compliance the Executive Director or designee will conduct review of all new resident files monthly for 2 months.
22VAC40-73-325-B
Based on the record review the facility did not ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. The record for resident #1 contains a progress note dated 9/26/24 and an emergency room visit note dated 9/26/24 documenting the resident experienced a fall on 9/26/24. Resident’s #1 record did not contain a fall risk rating after the resident’s fall that occurred on 9/26/24.
  2. Staff #1 confirmed the record for resident #1 did not contain documentation of a fall risk rating completed after 9/26/24.
  3. The record for resident #5 contains progress notes that documents on the following dates the resident experienced a fall: 6/23/24, 6/26/24, 7/02/24, 07/08/24, 07/09/24. Resident’s #5 record did not contain documentation of a fall risk rating completed after each fall.
  4. Staff #1 confirmed the record for resident #5 did not contain documentation of a fall risk rating completed after the following dates: 6/23/24, 6/26/24, 7/02/24, 07/08/24, 07/09/24.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-325-B Fall Risk Rating ¿ Facility cannot retroactively correct record for resident number one, who is no longer a resident of the community. The Executive Director or designee will correct record for resident number five. ¿ The Executive Director or designee will retrain the direct clinical staff on fall risk prevention procedures, interventions, and safety ratings post fall. ¿ The Executive Director or designee will audit 5% of the current resident records for compliance by 12/1/2024. ¿ To assist with ongoing compliance the Executive Director or designee will conduct reviews of all current resident records for fall risk ratings monthly for two months.
22VAC40-73-450-A
Based on the record review the facility did not ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #3, admission date of 9/23/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. Resident’s #1 ISP is dated as initiated on 9/26/24 and 9/27/24.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-450-A Individualized Service Plans ¿ Facility unable to correct Individualized Service Plan on Resident 3 as resident is no longer at the community. Facility able to correct Individualized Service Plan for resident number 1. The Executive Director, Health and Wellness Director or designee will review and update the Individualized Service Plan with current care needs for resident number 1 by 1/1/2025. ¿ The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators on Individualized Service Plans. ¿ The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit of 5% of current resident records for compliance by 1/1/2025. ¿ To assist with ongoing compliance, the Executive Director, Health and Wellness Director, and Health and Wellness Coordinator or Designee will conduct a review of all current resident Individual Service Plans monthly for two months. Individual Service Plans will be updated for residents during admission, annually, and for significant changes in condition.
22VAC40-73-680-E
Based on the record review the facility did not ensure medical procedures or treatment ordered by a physician or other prescribed shall be provided according to his instructions and documents. The documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident #2 contains the following physician orders: a physician order dated 7/31/24 that includes the following instructions: “(CBC)” complete blood count; a physician order dated 9/04/24 stating the following instructions: “labs ordered on 7/31/24 need results.” Resident’s #2 record did not contain lab results completed after the dates of 7/31/24 and 9/04/24.
  2. Staff #1 confirmed the record for resident #2 did not contain lab results completed after the date of 7/31/24 and 9/04/24.
  3. The record for resident #2 contains the following physician order: A physician order dated 8/14/24 that includes the following instructions: “podiatry eval & treat.” Resident’s #2 record did not contain documentation of a podiatry evaluation and/or treatment.
  4. Staff #1 confirmed the record for resident #2 did not contain documentation of completion of a podiatry evaluation and treatment.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-680-E Administration of Medications and Related Provisions ¿ The Executive Director, Health and Wellness Coordinator or designee will correct lab and podiatry orders for resident number 2 by 12/1/2024. ¿ The Executive Director, Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator or designee will retain direct clinical staff on how to input orders from physicians for Lab and podiatry orders. ¿ To assist with on-going compliance, the Executive Director, Health and Wellness Director and Health and Wellness Coordinator or designee will audit 5% of current resident records for physician’s orders monthly for two (2) months.
22VAC40-73-1110-A
Based on the record review the facility did not ensure prior to admitting a resident with a serious cognitive impairment due to a primary diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident’s file.
Evidence
  1. Resident’s #3 approval for placement in the special care unit dated 8/31/24 was not signed by the licensee, administrator, or designee and did not include a determination and justification for the decision to place the resident in the special care unit. Resident #3 progress notes document the resident was admitted to the special care unit on 9/23/24.
  2. The record for resident #5, admission date of 6/20/24, did not contain a determination and justification for placement in the special care unit completed by the licensee, administrator, or designee.
  3. Staff #1 confirmed the record for resident #5 did not contain a determination and justification for placement in the special care unit.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-1110-A Appropriateness of Placement and Continued Residence ¿ Facility does not have the ability to retroactively correct missing approval for placement in a special care unit on resident number 3 and resident number 5 as they are no longer residing at the community. ¿ The Executive Director or designee will retrain the Sales Manager and the direct care clinical staff regarding the requirements for placement in a special care unit and forms done upon admission. ¿ The Executive Director, and Sales Manager or designee will audit 5% of current resident files by 12/1/2024. ¿ To assist with ongoing compliance the Executive Director or designee will conduct review of all new resident files monthly for 2 months.
22VAC40-73-440-A
Based on the record review the facility did not ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission.
Evidence
  1. The record for resident #5, admission date of 6/20/24, did not contain a UAI.
  2. Staff #1 confirmed the record for resident #5 did not contain a UAI.
  3. The record for resident #3, admission date of 9/23/24, did not contain a UAI completed prior to admission. The UAI in the record is dated 9/24/24.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-440-A Uniform Assessment Instrument ¿ Facility does not have the ability to retroactively correct Uniform Assessment Instrument as resident number one (deceased) and resident number two (discharged) are no longer residing in the facility. ¿ The Executive Director or designee will retrain Sales Manager and Clinical Staff regarding the requirement for a Uniform Assessment Instrument completion prior to admission. ¿ The Executive Director or designee will audit 5% of the current resident population for completed Uniform Assessment Instruments by 12/1/2024. ¿ To assist with ongoing compliance the Executive Director or designee will conduct reviews of all new resident records monthly for two months.
22VAC40-73-320-B
Based on the record review the facility did not ensure to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for resident #1, admission date of 7/01/21, contains a risk assessment for TB dated 2/11/23. The resident’s record does not contain an annual risk assessment for TB completed after 2/11/23.
  3. Staff #1 confirmed the record for resident #1 did not contain an annual risk assessment for TB completed after the date of 2/11/23.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 11/1/24. 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 improvements to satisfy that objective. 22VAC40-73-320-B Physical examination and report-Subsequent tuberculosis evaluations ¿ Facility is unable to retroactively correct tuberculosis evaluation for resident number 1 because resident is no longer at the community. ¿ Executive Director or designee will retrain the Health and Wellness Director, Health and Wellness Coordinator, and Resident Care Coordinator regarding completion of the annual resident tuberculosis risk assessments by 12/1/2024. ¿ Newly hired Health and Wellness Director will be trained on the annual completion of all resident tuberculosis risk assessments by 12/1/2024. ¿ The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator, or Designee will conduct an audit of 5% of current resident tuberculosis risk assessments for compliance utilizing Point Click Care scheduled form by 12/1/2024. ¿ To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct review of all current resident tuberculosis risk assessments monthly for 2 months.
22VAC40-73-50-A
Based on the onsite record review the facility did not ensure to provide a statement to the prospective resident and the prospective resident’s legal representative, if any, that discloses information about the facility. The statement shall be on a form developed by the department and shall include information as listed in this subsection.
Evidence
  1. The record for Resident #3, did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their resident’s record.
  2. Staff #1 confirmed the record for resident #3 did not contain a disclosure statement.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 11/1/2024. 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 improvements to satisfy that objective. 22VAC40-73-50-A Disclosure ¿ Unable to retroactively correct signed disclosure upon admission for resident number 3. ¿ Executive Director or designee will retrain the Sales Manager and direct care clinical staff members regarding the requirement to have a signed disclosure statement on every resident prior to or upon admission to the facility. ¿ The Executive Director, Health and Wellness Director or Designee will conduct an audit of 5% of current resident records to verify completion of a disclosure statement by 12/1/2024. ¿ To assist with on-going compliance, the Executive Director, Sales Manager, Resident Care Coordinator, Health and Wellness Director or Designee will review all new resident’s records for completion of a disclosure statement at admission monthly for 2 months.
22VAC40-73-440-B
Based on the record review the facility did not ensure for private pay individuals, the UAI shall be completed by one of the following qualified assessors: an assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training.
Evidence
  1. Resident’s #1 UAI dated 8/14/24 was not signed by the facility’s administrator or the administrator’s designated representative.
  2. Resident’s #2 UAI dated 5/30/24 and 6/17/24 was not signed by the facility’s administrator or the administrator’s designated representative.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-440-B Uniform Assessment Instruments ¿ Executive Director or designee will correct Uniform Assessment Instrument of Resident number 1 and Resident number 2. The Executive Director, Health and Wellness Director or designee will review and update the Uniform Assessment Instruments with current care needs for resident’s number 1 and 2 by 12/1/2024. ¿ The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators on completion of the Uniform Assessment Instruments. ¿ The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit of 5% of current resident records for UAI completion by 12/1/2024. ¿ To assist with ongoing compliance, the Executive Director, Health and Wellness Director, and Health and Wellness Coordinator or Designee will conduct reviews of all current resident Uniform Assessment Instruments monthly for two months. Uniform Assessment Instruments will be updated for residents during upon admission, annually or a significant change in condition.
June 17, 2024Complaint survey1 violation
Inspection dates
06/17/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/17/24 from 2:55pm to 5:30pm. 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 6/10/24 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: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed:1 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 1 Observations by licensing inspector: 3 Additional Comments/Discussion: 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. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-720-D
Based on a review of resident records, it was determined that the facility did not ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out in a licensed assisted living facility when the written order is included in the individualized service plan (ISP).
Evidence
  1. The record for resident #3 contained evidence of a DNR order from the physician that was dated 5/15/24. However, the residents Individualized Service Plan (ISP) states the resident is full code. 2.Staff #1 confirmed the DNR order was not properly documented on the Individualized Service Plan (ISP) .
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/17/2024 and received 7/02/2024. 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. 22VAC40-73-720 Code Status • The Health & Wellness Director/Health or designee will update resident number 1 CODE status on Individual Service Plan to reflect status., • Executive Director or designee will provide re-education for the Health & Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator on Code state reflective on the Individual Service Plan. • The Health & Wellness Director or designee will conduct an audit on current residents Virginia Uniform Assessment Instrument and Individual Service Plan to verify the code status. • To assist with ongoing compliance, the Executive Director, Health & Wellness Director or designee will conduct audits on new admission records, monthly for two (2) months, to verify that the code status matches throughout the resident's medical record. The plan of correction is to be completed by October 2, 2024.
January 22, 2024Complaint survey2 violations
Inspection dates
01/22/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 01/22/24 from 11:25 am to 1:37 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 01/02/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation and review of the medication cart was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations, area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violations not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on the record review the facility failed to implement a written plan for medication management to include: Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication management plan dated 10/2018 includes the following: “All medication maintained within the community that fall under the DEA’s scheduled of II-V will be counted by a licensed nurse/RMA from the off going shift and one from the oncoming shift, both staff’s signature and the count of bingo cards and sheets will be documented on the Schedule II count sheet provided by the communities preferred pharmacy and the communities controlled Medication Inventory Sheet.”
  2. The facility’s Controlled Substance/MAR Change of Shift Audit Form for Dec. 2023 and Jan. 2024 did not include staff signatures for both the off going and oncoming shifts for the following dates and shifts: 12/10/23, 12/12/23: 7-3 shift 12/14/23, 12/15/23: 3-11 shift 12/20/23: 7-3 shift 12/27/23: 11-7 shift 12/28/23-12/20/23: 11-7, 7-3, and 3-11 shifts 01/01/24: 7-3, and 3-11 shifts 01/02/24: 3-11 shift 01/03/24-01/21/24: 7-3, 3-11, and 11-7 shifts.
Plan of correction
On January 23, 2024, the Health &Wellness Director (HWD) provided a re-in-service to the Licensed Practical Nurses (LPNs) and Registered Medication Aides (RMAs) reviewing the process of signing on and signing off on the controlled substance sheets to attest and verify that the controlled substance count is accurate. The HWD will provide another re-in-service of the same topic at our staff meeting on February 29, 2024. To assist with ongoing compliance, the HWD, Health & Wellness Coordinator (HWC) or designee will review the controlled substance book daily to verify the staff are signing on and off that they are counting controlled substances and that the count is accurate for two (2) months. The Executive Director (ED) or designee will perform an audit of the controlled substance book to verify that the LPNs and RMAs are signing each shift monthly for two (2) months.
22VAC40-73-680-M
Based on the onsite observation, and staff interview the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. Resident’s #1 physician orders dated 11/16/22, 11/22/23, and the Jan. 2024 medication administration record (MAR) includes the following PRN Orders: Acetaminophen 500mg, give 2 tablets every 8 hours as needed for pain; Haloperidol Lactate Oral, give 0.5 ml every 6 hours as needed for anxiety/agitation; Loperamide 2mg, give 2 mg by mouth as needed for diarrhea. During observation and review of the medication cart w/staff #1, residents #1 PRN medications to include acetaminophen, haloperidol, and Loperamide was not located on the medication cart.
  2. Staff #1 confirmed the following PRN medications ordered for resident #1 was not located on the medication cart and/or located and stored at the facility: Acetaminophen, Haloperidol, and Loperamide.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated February 16, 2024. 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 improvements to satisfy that objective. The HWD ordered resident #1’s Acetaminophen, Haloperidol and Loperamide on Jan 23, 2024. The HWD will conduct an audit on all residents’ medications on the medication cart and the physician orders to verify all medications ordered are on the cart. The HWD, HWC or designee will verify cart audits are being completed weekly per Brookdale policy for the next two (2) months. To assist with ongoing compliance, the ED or designee will complete random audits of the medication cart to verify PRN medication are on the medication cart monthly for two (2) months.
November 28, 2023Inspection1 violation
Inspection dates
11/28/2023
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 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: An unannounced monitoring inspection took place on 11/28/2023 from 9:45 am to 3:45 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 11/24/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: An observation of lunch and an activity was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall include the following: a description of identified needs based upon the admission physical examination, and other sources.
Evidence
  1. The record for resident #1, admission date 10/05/23, contains the following: a physical examination dated 09/28/23 that includes a diagnosis of “Psychosis, Dementia, Hallucinations;” an assessment for serious cognitive impairment dated 09/28/23 documents a diagnosis of “Hallucinations (Audiology & Visual);” a physician note dated 10/12/23 documents the resident was “brought into the Emergency Room w/hallucinations and was hospitalized 09/18/23-09/29/23.” Resident’s #1 ISP dated 10/05/23 does not include documentation of the resident’s identified needs to address the resident’s diagnosis of Psychosis and hallucinations.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Dec 4, 2023. 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 improvements to satisfy that objective. On December 12, 2023 Health & Wellness Director (HWD) and Health & Wellness Coordinator (HWC) in serviced on including behaviors from the resident’s history & physical form onto residents’ ISP. The HWD updated the resident’s ISP to reflect her diagnosis of psychosis and hallucinations. Executive director will complete random audits on new residents’ ISP’s for two months.
November 28, 2023Complaint survey3 violations
Inspection dates
11/28/2023
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 11/28/23 from 9:45 am to 3:45 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 11/09/2023 regarding allegations in the area(s) of: Resident Care and Related Services and Personnel. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of lunch and an activity were completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations, area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violations not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the facility the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years.
Evidence
  1. Resident’s #2 ISP dated 10/10/23 documents “resident has a pull cord in room and bathroom, due to cognitive impairment & functional decline, may not remember to use. Staff to do rounds every 2 hours.” Resident’s #2 record did not include documentation rounds were made for the month of October and November 2023.
  2. Resident’s #4 ISP dated 10/05/23 documents “staff to do rounds every two hours when asleep in bed & frequent rounding throughout the day. Has a pull cord, due to cognitive impairment & functional decline will not remember to use.” Resident’s #4 record did not include documentation rounds were made for the month of October and November 2023.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Dec 4, 2023. 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 improvements to satisfy that objective. Staff will be educated on the process and documentation of resident rounds every two hours during the evenings. HWD or HWC will enter rounds into the electronic medication administration system (EMAR) for each new resident. Nurses and Registered Medication Aids (RMA) will document in the EMAR system as rounds are completed. HWD or HWC will complete an audit to ensure each resident has the required rounding schedule entered into the EMAR system. Executive Director will do random audits of the EMAR to ensure rounds are entered on new residents for two months.
22VAC40-73-460-H
Based on record review the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing, at least twice a week but more often if needed or desired.
Evidence
  1. Resident’s #2 Individualized Services Plan (ISP) dated 10/10/23 documents the resident requires physical assistance with bathing to be provided by Direct Care Staff two times a week and as needed. Resident’s #2 bathing logs are dated as completed on 10/23/23, 11/02/23, 11/06/23, and 11/08/23. The facility did not provide documentation resident #2 received assistance with bathing, twice a week during the following timeframes: 10/10/23 through 10/23/23; 10/23/23 through 11/02/23; 11/08/23 through 11/22/23.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Dec 4, 2023. 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 improvements to satisfy that objective. On December 15, 2023 the care staff will be educated on correct shower days for each resident and the reporting process. The shift lead will verify that the showers are being completed per the Virginia Assisted Living Standards and lease agreement. HWD, HWC or designee will complete random audits to ensure all resident showers are completed twice weekly.
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. Resident’s #2 ISP dated 10/10/23 was not signed by the facility and the resident or the legal guardian.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Dec 4, 2023. 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 improvements to satisfy that objective. Resident was discharged from facility on 11/21/22. Health and Wellness Director (HWD) and Health and Wellness Coordinator (HWC) in-services on ISP process and signature. HWD, HWC or designee will complete an audit on all residents ISPs to ensure signatures are present. Executive Director or designee will do random audits for the next two months.
October 26, 2023Inspection6 violations
Inspection dates
10/26/2023
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 IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Personal Data
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: An unannounced renewal inspection took place on 10/26/223 from 8:20 am to 6:05 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: 38 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: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. The call bell system was monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident.
Evidence
  1. The record for resident #5 contains a risk assessment for TB dated 06/16/22. The facility provided evidence of a risk assessment for TB completed on 10/26/23 for resident #5, however the risk assessment was completed after the annual due date of 06/16/22.
Plan of correction
The Health & Wellness Director, Health & Wellness Coordinator and Resident Care Coordinator will be re-trained, by the DDCS, on annual TB risk assessments. The Health & Wellness Director/Health & Wellness Coordinator or designee will conduct audits on all resident’s charts to verify residents have TB risk assessments completed. The Health & Wellness Director or designee will have a physician complete any needed TB risk assessments. To assist with ongoing compliance, the Executive Director or designee will conduct an audit on all resident’s charts weekly for the next two (2) months to verify that TB risk assessments are completed. Plan of correction to be completed January 8, 2024.
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: a description of identified needs based upon the Uniform Assessment Instrument (UAI), physical examination, and other sources.
Evidence
  1. The record for resident #2 contains a Do Not Resuscitate Order (DNR) dated 03/10/21. Resident’s #2 ISP dated 09/28/23 documents the resident code status as Full Code.
  2. The record for resident #6 contains a DNR dated 03/25/16. Resident’s #6 ISP dated 04/28/23 documents the resident code status as Full Code.
  3. Resident’s #1 physical examination dated 10/04/23 documents the resident’s dietary needs as the following: 2mg sodium diet, soft and bite size. Resident’s #1 ISP dated 10/06/23 does not include the resident’s dietary needs as documented on the physical exam.
  4. Resident’s #1 UAI dated 10/06/23 documents mechanical and human help needed for walking. The resident’s ISP dated 10/06/23 does not include the human help support needed for walking.
Plan of correction
The Health & Wellness Director/Health and Wellness Coordinator or designee will conduct an audit on all current resident charts to verify that the resident code status matches throughout the resident’s medical record. The Health & Wellness Director/Health & Wellness Coordinator or designee will complete an audit of all current resident charts to verify dietary needs on History & Physical is documented within the individual service plan (ISP). Resident #4 Uniform Assessment Instrument (UAI) will be updated to reflect the need for mechanical help as indicated on the ISP. The Health & Wellness Director/Health & Wellness Coordinator or designee will conduct an audit on each residents UAI and ISP to verify the mechanical and human assistance needs are consistent. To assist with ongoing compliance, the Executive Director and Health & Wellness Director will conduct audits on new admission records, monthly for two (2) months, to verify that the code status match throughout the resident’s medical records. Plan of correction to be completed January 8, 2024.
22VAC40-73-550-G
Based on the resident record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal guardian or responsible individual.
Evidence
  1. 1 The record for resident #5 contains an annual review of the rights and responsibilities of residents dated 01/31/22. The facility provided evidence of a review of rights and responsibilities of residents reviewed for resident #5 dated 10/21/23, however the review was completed after the annual due date of 01/31/22.
Plan of correction
Business Office Manager & Programs Manager will be re-trained on tracking annual resident rights and confirming that each resident or legal representative have been consulted with annually. The Programs Manager/Business Office Manager or designee will conduct an audit on each resident’s chart to verify resident rights have been reviewed and signed by the resident or legal representative. The Programs Manager or Business Office Manager or designee will document these annual meetings and will obtain written acknowledgment from each resident or legal representative of having been so informed, which shall include the date of the review and shall be filed in the resident's record. Plan of correction to be completed January 8, 2024.
22VAC40-73-130-A
Based on the record review and staff interviews the facility failed to ensure all staff who are mandated reporters under code 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. The record for resident #3 contains a progress note dated 10/08/23 documenting the following: “resident #1 had hit resident #3 in his forehead with right side scarring, resident #1 was sent to the ER.” Resident’# 3 record contains a hospital discharge summary dated 10/08/23 documenting a diagnosis of “abrasion of face.” Resident’s #1 record contains an incident report dated 10/09/23 documenting the following incident occurred on 10/08/23: “resident #1 hit resident #3 above his eye with a rock that was wrapped inside of a napkin.” During an interview with staff #5, staff #5 reported resident #1 hit resident #3 in the face with a rock that was wrapped inside of a napkin on 10/08/23. Staff #5 confirmed the facility did not make an immediate report of suspected abuse as required under code 63.2-1606 of the Code of Virginia for the incident involving resident #3 to the local department or the Adult Protective Services hotline.
  2. Staff #5 reported the incident to the Virginia Beach, Adult Protect Services unit on 10/26/23.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Nov 1, 2023. 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 improvements to satisfy that objective. The Executive Director/Health & Wellness Director or designee will conduct re-training to all mandated reporter staff members on reporting suspected abuse, neglect and neglect. Staff #5 reported incident to Adult Protective Services on 10/26/23 and will use incident check list for all abuse incidents moving forward. To assist with ongoing compliance, the Executive Director/Health & Wellness Director or designee, will verify, weekly for two (2) months, that any incidents of suspected abuse, neglect, or exploitation of residents, has been reported timely. Plan of correction to be completed January 8, 2024.
22VAC40-73-640-A
Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in order.
Evidence
  1. The facility’s medication management plan includes the following statements: medications that have expired or have been discontinued will be disposed of per policy; when a new order/order change is received by the community, the nurse or RMA will fax a copy to the appropriate pharmacy and enter the changes in Point Click Care.
  2. During observation with staff #4 the following expired medications were observed in the medication cart: Morphine Sulfate Syringes ( 3 packs of 10) expired 08/02/23 for resident #8.
  3. The record for resident #1 contains a physician order dated 10/23/23 to discontinue the resident’s medication, Protonix. Resident’s #1 MAR documents the resident was administered the medication on 10/25/23 and the MAR does not include documentation the medication was discontinued on 10/23/23.
Plan of correction
Resident #8 morphine was taken off of the medication cart by HWD on 10/26/23 and disposed. All new orders will be entered by a licensed nurses and then verified by the Health & Wellness Coordinator and or the Health & Wellness Director or designee. ED to retrain HWD &HWC on medication cart audit, transcription of medications and discontinuing medications. To assist with ongoing compliance the Health and Wellness Coordinator or designee will audit medication carts weekly for the next two (2) months. Plan of correction to be completed January 8, 2024.
22VAC40-73-310-H
Based on the record review the facility failed to ensure in accordance with 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans.
Evidence
  1. The record for resident #1, admitted 10/06/23, contains a physical examination completed on 10/04/23 documenting the resident was prescribed the following psychotropic medications: Haldol 0.5mg, PRN for mood/agitation and Seroquel 25 mg at bedtime for agitation. Resident’s #1 record did not contain a treatment plan dated prior to or on admission for the psychotropic medications, Haldol 0.5mg and Seroquel 25mg.
Plan of correction
The Executive Director, Health & Wellness Director and Health & Wellness Coordinator, will be re-trained, by the District Director of Clinical Services (DDCS) or designee, on having physician complete psychotropic treatment plan form prior to admitting residents who take psychotropic medications. The Health & Wellness Director/Health & Wellness Coordinator or designee will conduct an audit on all resident’s charts who take psychotropic medications to verify psychotropic treatment plans are in place. In addition, to verify ongoing compliance, the Sales Manager will add Psychotropic treatment plan form to the admissions documents. The Executive Director/Health & Wellness Director or designee will conduct audits of new resident move-in documents, weekly, for the next two (2) months to verify psychotropic treatment plans are in place. Plan of correction to be completed by January 8, 2024.
August 22, 2023Complaint survey0 violations
Inspection dates
08/22/2023
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/22/23 from 8:40 am to 11:10am. 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 08/17/2023 regarding allegations in the area(s) of: Building and Grounds and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 34 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 7 Observations by licensing inspector: An observation of building and grounds to include resident rooms and common areas. An observation of breakfast was completed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 22, 2023Inspection1 violation
Inspection dates
08/22/2023
Areas reviewed
22VAC40-73 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 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: An unannounced monitoring inspection took place on 08/22/23 from 8:40 am to 11:10am. 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 08/09/2023 regarding allegations in the area(s) of: Personnel, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 34 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 7 Observations by licensing inspector: An observation of building and grounds to include resident rooms and common areas. An observation of breakfast was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on the record review the facility failed to ensure direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health institute, community college, hospital, volunteer rescue squad, or fire departments.
Evidence
  1. The record for staff #1, hire date 09/06/22, contains a certification in first aid from the American Red Cross completed on 02/24/21, valid for 2 Years (expired 02/24/23). The record does not contain a current certification in first aid.
  2. Staff # 6 emailed the Licensing Inspector on 08/24/23 a sign in sheet dated 06/13/23 titled CPR Training which included the name and signature of staff #1, however the facility did not provide evidence of staff #1 maintaining certification in first aid after the date of 02/24/23.
Plan of correction
•Staff #1 took the First Aid and CPR course on 6/13/23, we received a copy of the certification on 8/31/23. •The Business Office Manager (BOM) was retrained on tracking Employees First Aid & CPR certification by Executive Director on August 28, 2023. •BOM or designee will complete an audit of all associate files to verify First Aid and CPR certifications are up to date. •BOM or designee will schedule a First Aid and CPR class for September 18, 2013, for any associate requiring recertification. •To assist with ongoing compliance, once a month for three (3) months, the BOM or designee will complete an audit of associate files to verify the First Aid and CPR certifications are up to date.
August 8, 2023Inspection2 violations
Inspection dates
08/08/2023
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Provisions for Signaling and Call Systems
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: An unannounced complaint inspection took place on 08/08/2023 from 1:05 pm to 3:20 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 07/27/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 36 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on the record review and staff interview the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident #1 contains a physician note dated 07/13/23 that documents the resident was hospitalized for edema and congestive heart failure. During an interview with staff #1, staff #1 confirmed the resident was admitted to the hospital the dates of 07/04/23-07/12/23 for congestive heart failure. The facility did not notify the regional licensing office of the resident’s hospital admission the dates of 07/04/23-07/12/13.
  2. The record for resident #1 contains a progress note dated 07/12/23 that documents the resident was sent to the ER due to a fall and a skin tear to the left arm as a result of the fall. The facility did not notify the regional licensing office of the resident’s ER visit that occurred on 07/12/23.
Plan of correction
•The Executive Director, Health & Wellness Director were retrained on major incident reporting by the Executive Director on August 21, 2023 •The Executive Director, Health & Wellness Director or designee will report to the regional licensing office within twenty-four (24) hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident •To assist with ongoing compliance, the Executive Director, Health and Wellness Director or Designee will conduct an audit once a month for two months. The audit will verify all residents who have had any major incidents since 8/21/23 have been reported to the regional licensing office within twenty-four (24) hours.
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed by the resident or his legal guardian.
Evidence
  1. Resident #1’s ISP dated 06/06/23 and 07/13/23 was not signed by the resident or the legal guardian.
Plan of correction
•The Executive Director, Health & Wellness Director or designee will request a meeting with a resident and/or their legal representative to review the ISP and obtain a signed ISP from the resident or their legal representative. If the resident’s legal representative is not available for an in-person meeting, the Executive Director or designee will mail the ISP to the resident’s legal representative, The Executive Director or designee will note that the ISP has been mailed, in the resident’s medical record. If the resident or their legal representative provide verbal acknowledgment of the ISP, the acknowledgement will be noted in the resident’s medical record by the Executive Director or designee. •To assist with ongoing compliance, the Executive Director or Health & Wellness Coordinator or designee will conduct an audit once a month for two months to verify current residents have signatures on ISPs.
January 18, 2023Complaint survey1 violation
Inspection dates
01/18/2023
Areas reviewed
22VAC40-73 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 IMPAIRMENTS
Technical assistance
Ensure resident rooms do not contain medical equipment and supplies that do not belong to the resident.
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 01/18/23 from 10:25 am to 2:55 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 01/06/2023 regarding allegations in the area(s) of: Staffing and Supervision and Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the inside and outside of the facility was completed to include resident rooms and kitchen and dining areas. The following additional items were reviewed: staffing schedule, emergency preparedness drills, practice plan for emergencies, and the facility’s emergency water supply. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-750-B
Based on the onsite observation the facility failed to ensure bedrooms shall contain the following items: a table or its equivalent accessible to each bed, a sturdy chair for each resident, and drawer space for clothing and personal items.
Evidence
  1. The room for Resident #1 did not contain a table, sturdy chair, and drawer space. Staff #5 reported the resident moved into the room on 12/24/22.
Plan of correction
On January 18, 2023 the Maintenance manager moved resident # 1’s table, chair and dresser from her permanent room into her temporary room. Some of resident #1’s clothing that was hanging within the closet of her temporary room was put into the dresser, once we moved it into the room. January 31, 2023 an audit was completed by the Executive Director to ensure each resident in the community had a bed, table or its equivalent, a sturdy chair and drawer space for clothing and personal items. January 31, 2023 an in-service was completed Executive Director on Standard 750-B to train all managers on mandatory items for resident’s rooms whether temporary or permanent. Executive Director or designee to complete audit on all new residents’ rooms once a month for 3 months.
October 31, 2022Inspection5 violations
Inspection dates
10/31/2022,11/01/2022, 11/02/2022, 11/17/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Renewal An unannounced renewal inspection was conducted on-site on 10-31-22 (ar 08:15/dep 17:25) and 11-01-22 (ar 08:55/dep 16:55). The facility census was 29. A tour of the facility was conducted, medication pass observation with staff, staff and resident records reviewed, breakfast meal observed, an spiritual morning activity with exercise observed, emergency preparedness items reviewed (food, fire drill, emergency preparedness and first aid kits check conducted). An exit meeting conducted with the administrator on both days with violations reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on document reviewed and staff interviewed, the facility failed to ensure its medication management plan was implemented.
Evidence
  1. On 10-31-22 during medication pass observation with staff #4, resident #1’s 2022 medication administration record (MAR) documented resident prescribed Artificial Tears. The medication was not available to avoid a missed dosage/administration.
  2. Resident #2’s Miralax was not available to avoid a missed dosage.
  3. Resident #3 had medication on the cart that were no longer prescribed: Meloxicam and Tizanidine. These medications were recommended during the pharmacy review (5-4-22) to be discontinued for non-use in over 90 days and agreed to by the prescriber on 6-16-22.
  4. Staff #4 acknowledged scheduled medications for residents #1 and #2 were not available and medications for resident #3 that were discontinued were on medication cart #2.
Plan of correction
Resident #1’s artificial tears was ordered and is available on the medication cart. Resident #2’a Miralax was ordered and is available on the medication cart. Resident #3’s Meloxicam and Tizanidine were removed from the medication cart. -Health & Wellness Coordinator completed audit of medications on the medication cart to verify it was consistent with residents’ medication administration record (MAR). To assist with ongoing compliance, a medication cart audit will be completed monthly for 3 months, by the Health and Wellness Director, Health and Wellness Coordinator, or designee to verify the residents’ MAR is consistent with the medications in the medication cart and physician orders.
22VAC40-73-350-B
Based on record reviewed and staff interviewed, the facility failed to ensure it ascertain prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days.
Evidence
  1. On 10-31-22, resident #5’s record documented the resident’s date of admission as 12-14-21. The sex offender document was dated 1-6-22.
  2. Staff acknowledged the sex offender information was not obtained prior to admission.
Plan of correction
Executive Director or designee will audit current resident records to verify they have a registered sex offender check in their resident record. Executive Director or designee will note on the registry check, if it was ran after date of admission. -To assist with ongoing compliance, the Executive Director or designee will audit new residents records monthly for 3 months to verify if the sex offender registry check was completed for residents with a length of stay greater than 3 days.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of five records reviewed.
Evidence
  1. On 10-31-22, resident #1’s uniform assessment instrument (UAI) dated 9-10-22 noted stairclimbing assessed as no need. The individualized service plan (ISP) dated 9-10-22 documented stairclimbing as mechanical help/physical assistance needed.
  2. Resident #2’s UAI dated 9-20-22 assessed eating/feed need as mechanical help. The ISP dated 3-3-22 did not include this need. Resident’s UAI documented disorientation to time, place and situation. The ISP did not include how staff should re-orient resident. The record included a signed and dated Do Not Resuscitate (DNR) order dated 4-21-22, the ISP documented resident is a Full Code.
  3. Staff acknowledged the aforementioned residents’ ISPs did not include all assessed needs.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated November 17, 2022. 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 improvements to satisfy that objective. The Health & Wellness Director, Health & Wellness Coordinator, or designee will update resident #1’s uniform assessment instrument (UAI) and individuals service plan (ISP) to reflect the resident’s current stairclimbing needs. The Health & Wellness Director, Health & Wellness Coordinator, or designee will update resident #2’s UAI & ISP to reflect the resident’s current eating/feeding needs. Resident #2’s ISP will be updated to include how staff shall re-orient resident. –Resident #2’s ISP will be updated to reflect resident’s current Code status. The Health & Wellness Director, Health & Wellness Coordinator, or designee will complete an audit on all current resident records to verify that the resident’s Code status is updated on residents’ records and ISPs. To assist with ongoing compliance, the Health & Wellness Director, Health & Wellness Coordinator, or designee will complete an audit of ten (10) resident records monthly for 3 months to verify that both UAIs & ISPs reflect current resident assessed needs.
22VAC40-73-680-M
Based on document review, observation and staff interviewed, the facility failed to ensure medications ordered for PRN (as needed) administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 10-31-22, during medication pass observation with staff #4, a review of the October 2022 medication administration record (MAR) for resident #1, the following PRNs were not available: Miralax, Sugar Free Gum and Tylenol.
  2. Resident #2’s PRN Trazadone, Tylenol and Refresh eye-drops were not available.
  3. Resident #3’s Imodium was not available.
  4. Resident #4’s Calmoseptine not available.
  5. Staff #4 acknowledged the aforementioned residents’ PRN medications were not available during the medication cart check on 10-31-22.
Plan of correction
Resident #1’s PRN Miralax, Nicotine Gum and Tylenol were ordered and are available on the medication cart. Resident #2’s PRN trazadone, Tylenol and refresh eye-drops were ordered and are now available on the medication cart. Resident #3’s Immodium was ordered and is available on the medication cart. Resident #4’s calmoseptine was ordered and is available on the medication cart. -To assist with ongoing compliance, the Health & Wellness Coordinator completed an audit of medications on the medication cart to verify it was consistent with residents’ medication administration record (MAR). To assist with ongoing compliance, a medication cart audit will be completed monthly for 3 months, by the Health and Wellness Director, Health and Wellness Coordinator, or designee to verify the MAR is consistent with the medications in the medication cart and physician orders.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure admit or retain individuals with any prohibitive conditions or care needs.
Evidence
  1. On 10-31-22, resident #2’s October 2022 medication administration record (MAR) and physician order dated 9-21-22 documented resident prescribed Trazadone. The record did not include a psychotropic treatment plan.
Plan of correction
Resident number 2’s physician will create a psychotropic treatment plan based on her visit with Resident number 2 at the community on December 7, 2022. -Health & Wellness Director, Health & Wellness Coordinator, or designee will complete an audit of resident records for those resident with an order for a psychotropic medication to verify each resident has a psychotropic treatment plan. -To assist with ongoing compliance, the Executive Director or designee will complete an audits on new residents records monthly, for the next 3 months to verify a psychotropic treatment plan is in place for any resident with an order for a psychotropic medication.
August 23, 2022Inspection6 violations
Inspection dates
08/23/2022,08/29/2022,09/02/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring An unannounced monitoring inspection was conducted by two licensing inspectors (ERO/PLO) on 8-23-22. (Ar 07:39/ dep 5:20 p.m.) The facility census was 28. A tour of the facility was conducted, a medication pass observation conducted, breakfast meal was observed, water temperature take, call bell not checked due to it be inoperable on the day of the inspection. Staff records and interviews and resident records were reviewed. An exit was conducted on 8-23-22 with the administrator and health and wellness director. The Acknowledgement form was signed and a request for additional documents was asked to be sent to the inspector. The second preliminary exit meeting was conducted virtually on 8-29-22 with the administrator and regional staffs. The final exit meeting was conducted virtually on 9-2-22 with the administrator. The final meeting will be scheduled. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his/her legal representative.
Evidence
  1. On 8-23-22, resident #3’s ISP documented an update on 6-29-22. The updated ISP did not include a documented signature of the resident or legal representative.
  2. On 8-23-22, staff #1 and #2 acknowledged the aforementioned residents’ ISP did not include a required signature by the resident and/or legal representative.
Plan of correction
22VAC40-73-450-E Individualized service plans Date to be corrected: 10/12/2022 The resident #3’s individualized care plan (ISP) signed 7/25/22. Executive Director will train Health & Wellness Director, Health & Wellness Coordinator on individualized service plan process. The Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit on all residents individualized service plans to verify there is a signature and date. To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will conduct audits on all residents’ annual individualized service plans & updated individualized service plan monthly for two (2) months to verify required signatures.
22VAC40-73-680-I
Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all of the required information.
Evidence
  1. On 8-23-22, following the medication pass observation, a review of the resident’s medication administration records (MARs) were conducted. Resident #1’s August 2022 MAR did not include the initials of the direct care staff administering the medications on 8-16-22 at 9:00 p.m. (Seroquel and Mirtazapine). The following tasks were not documented on the MAR: (a) Brushing teeth with electric toothbrush at 9:00 p.m. and (b) safety check at 10:00 p.m.
  2. On 8-23-22, resident #2’s August 2022 MAR did not include the initials of the direct care staff administering the medications on 8-16-22 at 9:00 p.m. (Mirtazapine). The following tasks were not documented on the MAR: (a) Brushing teeth with electric toothbrush at 9:00 p.m. and (b) safety check at 10:00 p.m.
  3. On 8-23-22, resident #3’s August 2022 MAR did not include the initials of direct care staff administering the medication on 8-16-22 at 9:00 p.m. (Calcium tablet, removing compression stockings, eye drops in both eyes and Trazadone tablet). Safety checks at 10:00 p.m. was not was not initialed on the MAR by direct care staff.
  4. On 8-23-22, resident #4’s August 2022 MAR did not include the initials of direct care staff administering the medications on 8-16-22 at 2:00 p.m. (Seroquel). Safety checks at 10:00 p.m. on 8-11-22 and 8-16-22 were not initialed on the MAR by direct care staff.
  5. On 8-23-22, resident #5’s August 2022 MAR did not include the initials of direct care staff administering the medication on 8-16-22 at 9:00 p.m. (cholesterol control -10 mg tablet and Melatonin).
  6. On 8-23-22, resident #6’s August 2022 MAR did not include the initials of direct care staff signing and dating the MAR on 8-11-22 and 8-16-22 resident’s 10:00 pm safety check.
Plan of correction
22VAC40-73-680-I Administration of medications and related provisions Date to be corrected: 10/12/22 Registered Medication Aids & Licensed Practical Nurses will be retrained by Health & Wellness Director on initialing the medication administration record (MAR) after each medication is administered to resident in accordance with the physician order. Each off-going Registered Medication Aid /Licensed Practical Nurse will print missed medication report for on-coming Registered Medication Aid /Licensed Practical Nurse to review and sign. Resident Care Coordinator or designee will bring the missed medication report to the managers meeting every morning for review for two (2) months. To assist with ongoing compliance, the Health & Wellness Coordinator/designee will audit medication variance reports monthly for two months.
22VAC40-73-260-C
Based on document reviewed and staff interviewed, the facility failed to ensure the first aid/Cardiopulmonary resuscitation (CPR) listing posited was kept up to date.
Evidence
  1. On 8-23-22, during a tour of the facility with staff #1, the posted first/CPR listing listed staff #10’s first aid date as 6-12-22. Staff #11 and #12, direct care staff members, did not have a date for first aid. According to staff #1, staff would be scheduled for training.
  2. On 8-23-22, staff #1 acknowledged the posted first aid/CPR listing was not current/updated as required.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 9/2/22. 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 improvements to satisfy that objective. 22VAC40-73-260-C First aid and CPR certification Date to be corrected: 10/12/22 Staff #12 is no longer an employee. Staff #10 & Staff #11 CPR/First Aid certification will be updated by October 12, 2022. Executive Director will train Business Office Manager on upkeep of First Aid & CPR. To assist with ongoing compliance Business Office Manager/Designee will complete an audit of CPR/First Aid certification of all staff quarterly for one year. Executive Director will do random audits every quarter.
22VAC40-73-325-B
Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated after a fall.
Evidence
  1. On 8-23-22, resident #4’s individualized service plan (ISP) dated 1-26-22 documented the resident experienced a fall on 3-21-22 and 4-14-22. There was no evidence of a Fall Risk assessment being completed after the falls occurred on 3-31-22 and 4-14-22.
  2. On 8-29-22, staff acknowledged the fall risk rating was not completed following resident’s falls.
Plan of correction
22VAC40-73-325-B Fall risk rating Date to be corrected: 10/12/22 Executive Director will provide training to the Health & Wellness Director & Health and Wellness Coordinator Fall risk rating process. The Health & Wellness Director, Health & Wellness Coordinator and/Designee will update all residents fall risk ratings. To assist with ongoing compliance, the Executive Director and/Designee will complete an audit to verify the fall risk ratings are updated on three (3) randomly selected residents monthly for two (2) months.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six of six records reviewed.
Evidence
  1. On 8-23-22, resident #1’s uniform assessment instrument (UAI) dated 11-8-21 transferring need assessed as “no need”. The individualized service plan (ISP) dated 11-8-21 documented mechanical help using the arms of chairs to assist. Stairclimbing need assessed,” human help/supervision and is not performed”. The ISP documented not performed but needs supervision. The UAI documented resident disoriented some spheres all the time, the spheres were not documented. The ISP documented disoriented to time and place, but did not identify how to re-orient resident. The record included psychiatric progress notes for the resident, however, this need was not documented on the individualized service plan (ISP) dated 11-8-21.
  2. On 8-23-22, resident #2’s Donepezil allergy noted in psychiatric notes dated 7-6-22 not documented on resident’s ISP dated 11-5-21. Prescriber’s order for mechanical soft diet and serve meal in small sauces/bowl not documented on ISP. UAI dated 11-8-21, toileting need assessed “human help/physical assistance”. The ISP documented “mechanical help/physical, use of grab bars and assistance and resident to provide services”.
  3. On 8-23-22, resident #3’s UAI dated 5-3-22 documented a need of “mechanical and human help assistance for walking”. This need was not documented on the ISP dated 5-3-22.
  4. On 8-23-22, resident #4’s UAI dated 1-26-22 documented a need of “mechanical and human help for stairclimbing”. The UAI also documented a need of “mechanical and human help for stairclimbing”. These need were not documented on the ISP dated 1-26-22.
  5. On 8-23-22, resident #5’s UAI dated 7-13-22 documented, “bathing need as mechanical/human help/physical assistance”. The ISP dated 7-14-22 did not identify a mechanical item. Resident is “disoriented some spheres, sometimes”, the ISP did not document how resident should be redirected as needed. Resident’s behavior is assessed as, “wandering, passively- weekly or more”. This need is not address on the ISP. The ISP documented behaviors of resistive to care and will try to hit and kick staff during showers. The UAI did not assessed aggressive behavior as an identified need.
  6. On 8-23-22, resident #6’s UAI dated 6-1-22 documented bathing need assessed as “mechanical help/human help/physical assistance”. The ISP dated 4-7-22 did not identify the mechanical item.
  7. On 8-23-22, staff #1 and #2 acknowledged the aforementioned residents’ ISP did not include all assessed needs.
Plan of correction
22VAC40-73-450-C Individualized service plans Date to be corrected: 10/12/2022 Resident #1’s ISP was updated to reflect all of resident current needs (9/2/22). Resident #2’s ISP was updated to reflect all of resident’s current needs (9/1/22). Resident #3’s ISP was updated (9/8/22) toreflect a need of “mechanical and human help assistance for walking.” Resident #4’s ISP was updated (9/8/22) to reflect a need of “mechanical and human help for stairclimbing.” Resident #5’s UAI and ISP was updated (9/9/22) to reflect the current needs of the resident. Resident #6’s UAI and IPS was updated (9/8/22) to reflect the current needs of resident. To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will conduct Individualized Service Plan audits on 3 residents monthly for two (2) months.
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s personal and social data information required was kept current for four of six residents’ record.
Evidence
  1. On 8-23-22, resident #1’s individualized service plan (ISP) dated 11-8-21, August 2022 medication administration record (MAR) and psychiatric progress notes dated 8-10-22 documented resident allergy to Keflex and Ephedrine. The personal and social data form did not document allergy information.
  2. On 8-23-22, resident #2’s ISP dated 11-5-21 and August 2022 MAR documented allergy to Ibuprofen and Tramadol. The psychiatric progress notes dated 7-6-22 documented allergy to Donepezil, Ibuprofen and Tramadol. The personal and social data form did not document allergy information.
  3. On 8-23-22, resident #3’s August 2022 MAR documented allergy to Clindamycin, Codeine, Erythromycin, Penicillin, Prednisone, Xifaxan and Narcotics. The personal and social data form did not document allergy information.
  4. On 8-23-22, resident #4’s August 2022 MAR documented allergy to Aricept. The personal and social data form did not document allergy information.
  5. On 8-29-22, staff #1 acknowledged the resident’s personal and social data form was not updated to include all required information.
Plan of correction
22VAC40-73-380-B Resident personal and social information Date to be corrected: 10/12/22 Resident #1, resident #2, resident #3 and resident #4 personal and social data form has been updated to reflect their allergies on August 30th. Executive Director, Health & Wellness Director and/or designee will do an audit of all residents personal and social data forms to verify residents’ allergies are noted. To assist with ongoing compliance, an audit will be completed on all new residents monthly for two (2) months to verify allergies are noted on their personal and social data forms.
May 31, 2022Inspection10 violations
Inspection dates
05/31/2022,06/02/2022,06/13/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
A (2 days) on-site unannounced renewal inspection was conducted on 5-31-22 (ar 08:20 a.m./dep 18:00 p.m). Day 2, 6-2-22. The facility census on day 1 was 31. A medication pass observation, emergency preparedness items reviewed, activity, buildings and grounds tour, resident and staff records reviewed and interviews conducted. A preliminary exit meeting was conducted with the new administrator, the interim administrator and two other agency representatives. The final exit meeting was conducted virtually on 6-16-22 with the new administrator. The Acknowledgement of Inspection form was provided via email following each day 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six of six records reviewed.
Evidence
  1. On 5-31-22, resident #1 was observed with glasses. The uniformed assessment instrument (UAI) dated 5-3-22 documented walking and stairclimbing not performed. These needs were not documented on the resident’s individualized service plan (ISP) dated 5-4-22. Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six of six records reviewed. Evidence:
  2. On 5-31-22, resident #1 was observed with glasses. The uniformed assessment instrument (UAI) dated 5-3-22 documented walking and stairclimbing not performed. These needs were not documented on the resident’s individualized service plan (ISP) dated 5-4-22.
  3. Resident #2’s uniformed assessment instrument (UAI) dated 4-1-22 documented wheeling and stairclimbing need as not performed. The ISP dated 4-1-22 did not include these assessed needs.
  4. Resident #3’s glasses was not documented on the ISP dated 1-4-22.
  5. Resident 4’s record included a signed order dated 5-20-22 for oxygen 2 Liter via nasal cannula. This was not documented on the resident’s ISP dated 4-7-22.
  6. On 6-2-22, resident #5’s allergy documented on the facility’s “Emergency fact sheet” did not include resident’s allergy to pollen and environmental allergies. Resident’s uniformed assessment instrument (UAI) dated 4-6-22 documented bathing assessed as mechanical help/supervision. The ISP dated 4-6-22 did not document what mechanical help was needed to assist the resident. Walking need assessed as mechanical help only, the ISP documented resident required the use of the walker and staff supervision. Stairclimbing assessed as mechanical help/ physical assistance, the ISP documented use of handrail and supervision.
  7. Resident #6’s UAI dated 6-1-22 documented bathing need as mechanical help/physical assistance. The ISP dated 4-7-22 did not document what mechanical help was needed to assist the resident.
  8. Staff #1 and #2 acknowledged the aforementioned residents’ ISP did not include all assessed needs.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/13/22. 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 improvements to satisfy that objective. 22VAC40-73-450-C Individualized Service Plans • The District clinical team, Executive Director or Designee will update resident number 1, 2, 3, 4, 5 and 6 ISP and UAI to reflect current resident needs by 7/1/2022. • The Executive Director or Designee will provide education for current UAI/ISP certified LPN(s) on updating ISP as changes occurs by 7/1/2022. • The District clinical team, Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for current care needs by 7/01/2022. • To assist with ongoing compliance, The Executive Director, Health & Wellness Director or Designee will conduct Individualized Service Plan audits monthly on 3 resident for two (2) months.
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was updated as needed for a significant change of a resident’s condition for three of six records reviewed.
Evidence
  1. On 5-31-22, resident #1’s record included documentation of physical therapy (PT), occupational therapy (OT) and speech therapy (ST) services. On 6-2-22, staff #1 contacted the home-health agency and received the resident’s plan of care. Documents received noted OT last saw resident on 4-25-22, PT last seen on 3-30-22; ST last seen on 3-18-22 and skilled nursing (SN) last seen on 4-25-22. These services were not documented on the resident’s ISP dated 5-4-22. The resident’s date of admission documented as 4-26-22.
  2. Resident #3’s record documented on 1-19-22, physical therapy (PT) to evaluate and treat. Notes in the record dated 1-27-22 noted 3rd visit, 1-31-22 noted 4th visit and 2-1-22 noted 5th visit. Occupational therapy (OT) to evaluate and treat dated 1-19-22. Notes in the record dated 1-20-22 noted beginning of services, 1-31-22 noted 4th visit, 2-2-22 noted 5th visit, and and 2-7-22 noted discharge from services. Speech therapy (ST) to evaluate and treat dated 3-10-22. ST notes were dated on 1-20-22, 1-24-22 noted 2nd visit, 1-26-22 noted 3rd visit and 1-3-22 noted 4th visit. The resident’s ISP dated 1-4-22 did not include these services since admission on 1-4-22.
  3. On 6-2-22, resident #5’s record included recommendation for physical therapy, occupational therapy and skilled nursing on the admitting physical examination dated 3-29-22. Staff #1 contacted the home-health agency and the resident’s plan of care was provided. The plan of care received on 6-2-22 documented physical and occupational therapy services evaluation requested date was 4-21-22. The document also noted resident received 6 visits from physical therapy and 5 visits from occupational therapy. The resident’s ISP dated 4-6-22 did not include home-health services since admission on 4-6-22.
  4. Staff #1 and #2 acknowledged the aforementioned residents’ ISP was not updated to reflect resident’s change in condition.
Plan of correction
• The District clinical team, Executive Director or Designee will update resident number 1, 3 and 5 ISP to reflect current resident care needs by 7/1/2022. • The Executive Director or Designee will provide education for current UAI/ISP certified LPN(s) on updating the ISP as changes occurs to reflect current care needs by 7/1/2022. • The District clinical team, Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for current care needs and make needed updates by 7/01/2022. • To assist with ongoing compliance, The Executive Director, Health & Wellness Director or Designee will conduct random Individualized Service Plan audits for residents current care needs monthly for two (2) months.
22VAC40-73-680-M
Based on observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 6-2-22 during a medication cart check with staff #3, resident #2’s PRN Tylenol was not available on the cart. A check was made of the medications in the nursing station, but the resident’s Tylenol was not available. A check of the April 2022 medication administration determined the medication was also not available in April 2022.
  2. Staff #3 acknowledged the aforementioned resident’s PRN Tylenol was not available on the cart on 6-2-22.
Plan of correction
• The Executive Director, Health and Wellness Director or Designee will audit physician orders to medication available for resident number 3 and will coordinate with pharmacy that all prn medications are present and available by 7/31/2022. • The Executive Director, Health & Wellness Director or Designee will provide education on administration of medication and administration in accordance with physician’s orders and availability of prn medications for current LPN’S and RMA’s no later than 7/31/2022. • The District Clinical Team, Executive Director, Health & Wellness Director or Designee will complete an audit of all current residents’ physician orders to medication availability and coordinate with pharmacy to have all medications routine and prn available for the resident by 7/1/2022. • To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will audit all current resident physician’s orders and medication availability once a week for two (2) months.
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure 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. The services provided by each shall be included on the individualized service plan (ISP) for two of six records reviewed.
Evidence
  1. On 5-31-22, resident #4’s record included a hospice plan of care of services from a local agency which included nursing, social worker and certified nurse aid. The hospice services were not documented on the individualized service plan dated 4-7-22.
  2. On 6-2-22, resident #6’s ISP documented resident receiving hospice services. Staff #1 contacted agency and received a copy of the resident’s plan of care. A review of the resident’s plan of care received from the agency on 6-2-22 documented resident receiving social work, volunteer and chaplain services. The services provided were not documented on the ISP dated 4-7-22.
  3. Staff#1 and #2 acknowledged the aforementioned residents’ ISP did not include all hospice services.
Plan of correction
• The District clinical team, Executive Director or Designee will update resident number 4 and 6 ISP to reflect current resident hospice plan of care and/or obtain the Hospice written Plan of Care for the residents records by 7/1/2022. • The Executive Director or Designee will provide education for current UAI/ISP certified LPN(s) on updating the ISP for Hospice plan of care as changes occurs by 7/1/2022. • The District clinical team, Health & Wellness Director or Designee will audit all current resident that receive Hospice Services and the Individualized Service Plans for current hospice plan of care by 7/01/2022. • To assist with ongoing compliance, The Executive Director, Health & Wellness Director or Designee will conduct random Individualized Service Plan audits for residents receiving Hospice Services monthly for two (2) months.
22VAC40-73-1180-B
Based on observation and staff interviewed, the facility failed to ensure on the safe, secure unit, when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. On 5-31-22 during a tour of the facility with staff #4, eleven screws and metal brackets were observed in the window in room #15.
  2. On 6-2-22, a vase filled with various chains was observed on the dresser in room #15.
  3. Staff #1 and #2 acknowledged these items may be harmful to the residents on the safe, secure unit.
Plan of correction
• The Executive Director and Maintenance Director immediately removed vase with chains and secured maintenance supplies from apartment 15. • The Executive Director, Maintenance Director or Designee will provide education for all current associates on environmental precautions and providing a safe, secure environment for residents no later than 7/1/2022. • The Executive Director, Health and Wellness Director, Managers or Designee will complete a full sweep of memory care unit daily for two weeks to assist with environmental precautions and secure any items found by 7/1/2022. • To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct random room sweeps weekly in the memory care unit for 2 months.
22VAC40-73-380-A
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s personal and social data form included all required information and was kept current for four of six record reviewed.
Evidence
  1. On 5-31-22, resident #1’s personal and social data form was missing the resident’s date of admission.
  2. Resident #3’s personal and social data form was missing the resident’s date of admission, physician’s information, dentist information and resident’s interest/hobbies.
  3. Resident #4’s personal and social data form was missing resident’s date of admission and Gabapentin and Doxylamine allergy.
  4. On 6-2-22, the facility’s “Emergency fact sheet” documented the resident #5’s allergies were pollen and environmental. This information was not documented in the allergy section of the personal and social data form. The resident’s social data form documented the resident’s military service was Navy. A copy of the resident’s military card in the record noted the resident was Army.
  5. Staff #1 and #2 acknowledged the resident’s personal and social data form did not include all required information.
Plan of correction
• The Executive Director, Resident Care Coordinator, Business Office Manager or Designee will ascertain resident personal and social data for resident number 1, 3, 4 and 5 no later than 7/1/2022. • The Executive Director or designee will provide education for the Sales Manager, Resident Care Coordinator and Business Office Manager on resident personal and social data prior to or at date of admission and Virginia regulations to be completed by 7/1/2022. • The District clinical team, Executive Director or Designee will audit of all current resident records for resident personal and social data to be completed and corrected by 7/1/2022. • To assist with ongoing compliance, the Executive Director, Health and Wellness Director or Designee will audit all new admission resident record for resident personal and social data and compliance once a month for two months.
22VAC40-73-320-A
Based on document reviewed and staff interviewed, the facility failed to ensure the resident’s admitting physical examination was completed within 30 days preceding admission and included all of the required information for a resident.
Evidence
  1. On 5-31-22, resident #3’s physical examination in the record was signed and dated 11-19-21. The resident’s date of admission was documented as 1-4-22. The physical also did not include the resident’s height.
  2. Staff #2 acknowledged the aforementioned resident’s physical was not in compliance with the regulation for admissions.
Plan of correction
• Unable to retroactively correct Physical Examination and report date upon admission for resident number 3. • Executive Director to provide education for the Sales Manager and Resident Care Coordinator regarding resident Physician physicals completed 30 days or less prior to admission to assisted living community by 7/1/2022. • The District clinical team, Executive Director, Health and Wellness Director or Designee will conduct audits of all current resident physical examination and report for compliance by 7/1/2022. • To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct review of all new resident physical examination dates at admission date for 2 months.
22VAC40-73-610-B
Based on observation and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to the residents.
Evidence
  1. On 5-31-22, at 10:35 a.m. staff #6 was observed posting the current menu for the week and the daily menu. The daily breakfast menu for the day, 5-31-22 was posted following the breakfast meal being served.
  2. Staff #6 acknowledged the current weekly menu was not posted as required.
Plan of correction
• The Executive Director and Dining Manager immediately corrected posting of current menus and snacks at time of inspection. • The Executive Director or Designee will provide education for the Dining Manager on posting current weekly menus and snacks in a conspicuous location for the residents by 7/1/2022. • To assist with ongoing compliance, The Executive Director, Dining Service Manager or Designee will conduct random Menu and Snacks schedule postings weekly for two (2) months.
22VAC40-73-680-N
Based on staff interviewed, the facility failed to ensure stat-drug may only be used when the drug is removed from the stat-drug box and administered by a nurse, pharmacist, or prescriber licensed to administer medications. Registered medication aides are not permitted to either remove or administer medications from the stat-drug box.
Evidence
  1. On 5-31-22 during the medication pass observation with staff #3, resident #2’s Furosemide was not available in the facility to administer the 09:00 a.m. dosage as prescribed.
  2. Later staff #3 during the afternoon, the inspector was informed the resident was given the medication from the facility’s stat-drug box. According to staff #3, Registered Medication Aide (RMA) and verified by staff #9 (agency nurse) resident # 3 received the Furosemide from the facility’s stat-box. According to staff #3 and staff #9, staff #9 gave staff #3 the Furosemide medication to administer to the resident.
  3. During conversation with staff #9, staff stated it was okay for staff #3 to give the medication because staff #9 pulled it from the facility’s stat-drug box.
  4. On 5-31-22 staff #3 and #9 acknowledged staff #3’s administration of medication from the facility’s stat-box as directed to do so by staff #9 was not in accordance with the Assisted Living Regulations.
Plan of correction
• The Licensing Inspector provided clarification of Virginia regulation 22VAC40-73-680-N for District Director of Clinical Services, District Director of Operations, Interim Executive Director and Area Nurse Manager at time of Inspection. Immediate correction made on 5/31/2022. • The Executive Director, Health & Wellness Director or Designee will provide education on the use of and regulations regarding Stat-drug boxes in Virginia for all current LPN’S and RMA’s no later than 7/1/2022. • To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will provide on-going education for current LPN’s and RMA’s on the use of Stat-drug boxes in Virginia monthly for two (2) months.
22VAC40-73-680-D
Based on record reviewed and staff interviewed, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. On 5-27-22, the inspector received an incident report for a medication error for resident #7. On 6-2-22, the record included a note of a request from the resident’s spouse for lab-work, spouse suspected resident may have a UTI. The record included an order to “obtain UA and Urine Culture for possible UTI start date of 3-30-22”.
  2. On 4-6-22 a prescriber’s order was provided to the facility. The order was for Bactrim DS 800 mg-160 mg oral tablet; Take 1 tab(s) orally every 12 hours for 7 day(s). Start date: 4-6-2022, End date: 4-12-22.
  3. The April 2022 medication administration record (MAR) documented Bactrim DS tablet to be administered 1 tablet by mouth every 12 hours every 7 day(s). The MAR for April 2022 and May 2022 documented the resident received the antibiotic twice a day on Thursday of each week, beginning 4-7-22 and continued until the error was discovered in May.
  4. Staff #1 acknowledged the aforementioned resident’s antibiotic was not administered per the prescriber’s instructions.
Plan of correction
The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/13/22. 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 improvements to satisfy that objective. • The Executive Director, Health and Wellness Director or Designee will audit Physician orders to Admiration Record for resident number 7 and make updates as needed by 7/1/2022. • The Executive Director, Health & Wellness Director or Designee will provide education on administration of medication and administration in accordance with physician’s orders for current LPN’S and RMA’s no later than 7/1/2022. • The District Clinical Team, Executive Director, Health & Wellness Director or Designee will complete an audit of all current residents’ current active physician orders to medication administration record to assist with medications administrated as ordered by 7/1/2022. • To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will audit all current resident new physician’s orders and medication records once a week for three (3) months.
February 18, 2022Complaint survey7 violations
Inspection dates
02/18/2022; 02/23/2022; 03/11/2022; 03/14/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
An unannounced complaint inspection was conducted on 2-14-22 regarding a complaint that came to the regional licensing office alleging resident's care and medications were not be taken care of in the facility, resident had wounds on sacral area. Interviews and records reviews were conducted and determine the allegation to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days: 3-26-22.
Violations
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed as the condition of the resident changes.
Evidence
  1. Resident #1’s individualized service plan (ISP) with needs outcome achieved date of 4-26-22 was not updated to include resident’s home-health services for wound of sacral area, Occupational Therapy (OT) services noted in record, last visit (#5) dated 1-19-22. Physical Therapy (PT) services noted in record with a discharged date of 2-4-22.
  2. Resident #2’s record did not have a current updated annual review of the ISP. The last ISP in the record is dated 11-19-20 with updated needs with an outcome date of 12-15-21 and 12-22-21.
  3. Resident #3’s individualizes service plan was not updated to include home-health services, skilled nursing for wound care services which began on 12-2-22 and documentation of services being received as of 2-18-22. Occupational Therapy services provided beginning 6-12-21 with “services one time week one and two times week two to maximize safety and independence with adls and functional mobility and decrease impairments limiting function”. Physical Therapy services provided beginning 6-15-21 to include “strengthening, balance training, gait training and transfer training” per home-health notes. Speech Therapy (ST) services beginning 6-15-21, “dysphagia assessment due to complaints of food or drink getting stuck in throat”. ST plan of care of services: one time one week, two times week for five weeks and one time for one week. The resident’s ISP dated 6-8-21 did not include these home-health services
  4. Staff #1 and #2 acknowledged the aforementioned residents’ ISPs was not updated to include changes in condition.
Plan of correction
• Unable to retroactively correct resident number 2 Individualized Service Plan as resident number 2 no longer in community. • The Executive Director or Designee will provide education for the Health and Wellness Director on updating Individualized Service Plans as changes occur by 5/09/2022. • To assist with ongoing compliance, The Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for updates needed by 5/09/2022.
22VAC40-73-680-E
Based on record reviewed and staff interviewed, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident’s record.
Evidence
  1. Resident #3’s progress notes dated 12-6-21 documented resident returned to facility from emergency room following an unwitnessed fall with a “hand brace on right wrist”. Progress noted dated 12-9-21 documented resident to follow-up with orthopedic for wrist. Physician’s order dated 12-8-21 documented resident is to wear left brace at all times. The record did not have documentation of the orthopedic visit and documentation of the resident wearing the brace. Staff #2 stated the resident refused to wear brace, there was no documentation in the record of refusal.
  2. Staff #1, #2 and 3 acknowledged the aforementioned resident’s record did not have documentation of resident wearing brace to left wrist and no documentation of resident’s representative taking resident for orthopedic visit.
Plan of correction
• The Health & Wellness Director or Designee will provide education on administration of treatments ordered by a physician according to his instructions for current RMAs and LPNs by 5/09/2022. • The Health & Wellness Director or designee will review the physician’s treatment orders for three residents no later than 5/09/2022. • To assist with ongoing compliance, the Health & Wellness Director or Designee will audit all current resident new physician’s treatment orders and once a week for four weeks.
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or his designee who has developed the plan and the resident or his legal representative.
Evidence
  1. Resident #1’s individualized service plan (ISP) with the assessed need date of 4-26-21 and expected outcomes dates of 4-26-22 did not include a date the developer completed the plan and no signature and date for the resident and or legal representative.
  2. Staff #1 and #3 acknowledged the aforementioned resident’s ISP did not have a dates and signatures as required.
Plan of correction
• The Executive Director or Designee will provide education to The Health & Wellness Director on ensuring ISP signature and date of developer and signature and date of legal representative by 5/09/2022. • The Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for signatures and dates of developer and signatures and dates of legal representative by 5/09/2022. • To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan audits for signatures and dates of developer and signatures and dates of legal representative of random resident charts once a week for 4 weeks.
22VAC40-73-70-A
Based on record reviewed and record reviewed, the facility failed to ensure it report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. On 2-18-22, the inspector requested a list of residents with wounds in the facility. Residents #1, #2 and #3’s records were reviewed and wound care services were noted.
  2. Resident #1’s Progress notes documented resident returning from the emergency room on 1-11-22 with “Allevyn on buttocks for pressure ulcer”. On 1-12-22, progress notes documented a local home health agency contacted to address skin care evaluation. On 1-20-22 the skilled nurse from a home-health agency documented a sacral/coccyx wound, .8 X .3 X .1.
  3. Resident #2’s Hospice progress notes documented “mild redness to sacral area on 9-21-2; 0.5 X 0.5 cm opened to sacrum on 10-22-21; wound scrubbed, collagen powder placed in wound bed w/solosite & covered w/ calcium alginate and covered with sterile dressing noted on 11-29-21; pt w/3 X 4 cm, 4cm depth stage 4 wound w/eschar & odor, order for Flagyl & Cipro.
  4. Resident #3’s record documented “skilled nursing providing wound care services to left upper extremities and right upper extremities & right face skin tears.
  5. Staff #1 acknowledged stage 4 wound was not reported to the regional licensing office.
Plan of correction
• Unable to retroactively correct date of notification. Resident number 2 no longer in community. • The Executive Director will provide education for the Health & Wellness Director, Resident Care Coordinator and current nurses on timely and accurate incident reporting by 5/09/2022. • To assist with ongoing compliance, The Health and Wellness Director or Designee will report timely and accurately any major incident that has negatively affected or that threatens the life, health, safety, or welfare of current residents
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of three residents .
Evidence
  1. Resident #1’s uniformed assessment instrument (UAI) dated 4-26-21 documented bathing assessed as physical assistance. The individualized service plan (ISP) with an outcome date of 4-26-22 documented mechanical help and physical assistance. Bowel and bladder need assessed as continent. The ISP documented resident wears protective briefs. Transfer need assessed as no help; however, toileting need documented resident requires supervision for safe transfer. Stairclimbing assessed as not performed. The ISP did not document how service, if need would be performed and who would perform services. Behaviors not documents on UAI; however, ISP documented 11-30-21 date identified, resident assessed with aggressive behavior.
  2. Resident #3’s uniformed assessment instrument (UAI) dated 6-8-21 assessed walking need as no help. The ISP dated 6-22-21 documented resident needed a walker. Wheeling and stairclimbing need assessed as not performed. The ISP did not document how and who would provide services.
  3. Staff #1 and #2 acknowledged the aforementioned resident’s ISP did not include all assessed needs.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 3/14/2022 and received 3/16/2022. 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 Individualized Service Plan. Resident number 2 no longer in community. • The Individualized Service Plans (ISP) for Resident number 1 and resident number 3 will be reviewed by the Executive Director, Health and Wellness Director or Designee and will be updated to reflect current identified needs, services, who will provide services, expected outcomes and completion no later than 3/30/2022. • The Executive Director will provide education for the Health and Wellness Director on Individualized Service Plans (ISP) compliance by 5/09/2022. • The Health and Wellness Director or Designee will audit of all current residents Individualized Service Plans (ISP) for care services provided completed by 5/09/2022.
22VAC40-73-440-K
Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) was in compliance with 22VAC30-110 for one of three residents.
Evidence
  1. Resident # 2's uniformed assessment instrument (UAI) dated 10-15-21 was completed by a staff member, but the second signature was not completed by the administrator or designee.
  2. Staff #1 and 3 acknowledged the UAI was not signed by the designee or administrator as required.
Plan of correction
• Unable to retroactively correct discharged resident’s initial Uniform Assessment Instrument. Resident number 2 no longer in community. • The Executive Director or Designee will provide education to Health & Wellness Director and Resident Care Coordinator for Uniform Assessment Instrument required signatures by 5/09/2022. • To assist with ongoing compliance, The Health & Wellness Director or Designee will audit all current resident Uniform Assessment Instrument for required signatures no later than 5/09/2022.
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice services are 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. The services provided by each shall be included on the individualized service plan.
Evidence
  1. Resident #2’s individualized service plan did not include the hospice services being provided by the new hospice agency. The resident changed hospice agency approximately 2-11-22 (date of hospice care- comfort medications order).
  2. Staff #1 and #2 acknowledged the resident’s ISP should have been updated to include the change in services and the services provided by the new provider.
Plan of correction
• Unable to retroactively correct Individualized Service Plan for resident number 2, as resident number 2 no longer in community. • The Executive Director or Designee will provide education for the Health and Wellness Director and Health on Individualized Service Plans (ISP) compliance by 5/09/2022. • To assist with ongoing compliance, the Health and Wellness Director or Designee will audit random current residents Individualized Service Plans (ISP) for identified hospice services and completion of ISP once a week for 4 weeks.
August 13, 2021Complaint survey11 violations
Inspection dates
8/13/2021;10/19/2021;10/20/2021;10/28/2021;11/8/2021
Areas reviewed
None
Comments
A non-mandated complaint inspection was initiated on 8-12-21 and concluded on 11-19-21. A complaint was received by the department regarding allegations in the areas of resident care and related services, staff training and knowledge, oxygen care and training, and staff attitude. 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 licensing inspector conducted an on-site observation at the facility on 10-1-21. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found in the violation notice.
Violations
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit nor retain individuals with psychotropic medication without a treatment plan for three of four records .
Evidence
  1. Resident #1’s May, June and July 2021 medication administration record (MAR) documented resident was administered Escitalopram Oxalate and Mirtazapine. The resident’s Order Summary document dated 5-4-21 documented the aforementioned medications. The resident’s record did not contain documentation of a treatment plan for the prescribed psychotropic medications.
  2. Resident #3‘s September 2021 medication administration record (MAR) documented resident is administered Effexor, Seroquel and Mirtazapine. The resident’s record did not contain documentation of a psychotropic treatment plan.
  3. Resident #4’s September 2021 medication administration record (MAR) documented resident is administered Lamotrigine, Lexapro, Remeron and Trazadone. The resident’s record did not contain documentation of a psychotropic treatment plan.
  4. On 11-4-21, 11-15-21 and 11-19-21 during exit interview, staff #1 acknowledged the facility did not have a treatment plan for the residents’ psychotropic medications
Plan of correction
• Resident number 1 no longer in community. Psychotropic treatment plan present on physicians order summary for May 2021 and present in resident record at time of in person survey. Requesting consideration for removal of citation. • Resident number 3 psychotropic treatment plan present on physicians order summary for September 2021 and present in resident record at time of in person survey. Requesting consideration for removal of citation. • The Executive Director, Health and Wellness Director or Designee will provide education on psychotropic treatment plans in accordance with VDSS regulations with current clinical associates by 3/28/2022. • To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct random psychotropic treatment plan audits monthly for 2 months.
22VAC40-73-650-B
Based on record review and staff interview, the facility failed to ensure the physician or prescriber’s orders identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. Resident #3’s Active Medications List dated 9-24-21 did not include the diagnosis, condition, or specific indications for administering the following medications: (a) Amlodipine (b) Loratadine (c) Niacin (d) Coreg (f) Namenda and (g) Esbriet.
  2. Staff #1 acknowledged during exit, resident’s physician’s order did not document the diagnosis, condition, or specific indications for administering each drug.
Plan of correction
Not published by VDSS.
22VAC40-73-700-5
Based on record review and staff interview, the facility failed to ensure that all direct care staff responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment.
Evidence
  1. Staff members #4, #5 and #7 did not have documentation of oxygen training. Staff were responsible for assisting resident #1 with oxygen supplies and care. Resident #1 required to have oxygen via nasal cannula continuously. The facility’s oxygen policy CS-40-18 documented staff should be trained to assist with resident’s oxygen. The policy also documented the resident’s need for oxygen should be documented on the resident’s service plan.
  2. During the exit staff #1 was reminded of staff being training according to the needs of the training.
Plan of correction
Not published by VDSS.
22VAC40-73-100-C-2
Based on observation and staff interview, the facility failed to ensure it's infection control protocol was implemented during a blood glucose observation.
Evidence
  1. During the medication observation with staff #9, resident #2's glucometer was observed to not be labeled with resident's name.
  2. During the blood glucose observation staff #9 did not have a cleaned environment to place blood glucose supplies. The items used during the process were placed on the resident's bed.
  3. Staff #1 informed of what was observed during the medication observation pass.
Plan of correction
• The Executive Director, Health and Wellness Director or Designee will provide retraining on Infection Control Program and a medication pass observation for staff number 9 by1/31/2022. • The Executive Director, Health and Wellness Director or Designee will provide reeducation for current LPN’s, RMA’s and direct care associates in regards to the Infection Control Program by 3/28/2022. • To assist with ongoing compliance, the Health and Wellness Director or Designee will provide random Infection Control Program Observations with direct care staff monthly for three months.
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to ensure resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. Resident #1’s May 4, 2021 and June 9, 2021 Order Summary Report documented resident’s medication Tiotropium Bromide Monohydrate Capsule 18 MCG (Spiriva) order dated 4-9-21. Progress Notes documented the facility not having the medication in the facility: (a) 4-13-21, awaiting pharmacy, (b) 4-22-21, staff contacting pharmacy (c) 4-23-21, staff documented will order, (d) 5-13-21, awaiting pharmacy, (e) 5-14-21, needs attention from HDW (Health and wellness director) (f) 5-15-21, awaiting pharmacy, staff will call pharmacy (g) 5-16-21, medication not available and 5-20-21, Health and Wellness Director (HWD) action needed.
  2. Resident #1’s May and June 9, 2021 Order Summary Report documented resident’s medication Anoro Ellipta Aerosol Powder Breath Activated 62.5-25MCG/INH (Umeclidinium-Vilanterol) order dated 4-9-21. Progress Notes documented medication not available: (a) 5-10-21, not in cart, will order (b) 5-12-21, awaiting pharmacy will give a call (c) 5-15-21, waiting on pharmacy, will call to check on it and (d) 5-17-21 Anoro Ellipta Aerosol Powder Breath Activated 62.5-25MCG/INH medication discontinued. There was no physician order provided for discontinuation of medication. The resident’s July 7, 2021 Order Summary Report documented the Anoro Ellipta Aerosol Powder Breath Activated 62.5-25MCG/INH order date 6-17-21. (e) Progress Notes dated 6-20-21, documented medication not on cart, different dose dated (f) 6-21-21 documented facility awaiting medication from pharmacy.
  3. During exit meeting, staff stated resident no longer in facility
Plan of correction
• Resident number 1 is no longer in community. • The Executive Director, Health & Wellness Director or Designee will provide reeducation on Medication Management Plan for current LPNs and RMA’s no later than 3/28/2022. • The Health & Wellness Director or designee will audit the medication administration orders for three residents no later than 3/28/2022. • To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will audit 10 current resident medication administration records once a month for three months.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure the resident’s medication was administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing
Evidence
  1. Resident #1’s June 6, 2021 Order Summary Report document Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/NH (Fluticasone Furoate-Vilanterol) was discontinued on 6-26-21. The June medication administration (MAR) record did not document medication’s discontinuation, staff initials documented medication continued to be administered for the month of June 2021. The resident’s July 2021 MAR also documented the resident received the medication on 7-1-21 and 7-2-21. 2. During the exit meeting staff #1 informed of information documented on the resident’s MAR and Progress notes.
Plan of correction
• Resident #1 no longer in community • The Health & Wellness Director or Designee will provide reeducation on administration of medication and administration in accordance with physician’s orders for current RMA’s no later than 2/15/2022. • The Health & Wellness Director or designee will review the physician’s orders for three residents no later than 2/15/2022. • To assist with ongoing compliance, the Health & Wellness Director or Designee will audit all current resident new physician’s orders and medication records once a month for three (3) months
22VAC40-73-650-A
Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. Resident 1’s April and May 2021 medication administration record (MAR) documented Furosemide 20 mg for three days and May 2021 MAR documented Furosemide 20 mg daily, starting on 5-13-21. May 2021’s MAR documented Amoxicillin 500mg four times a day, starting 5-19-21. The June 2021 MAR documented Amoxicillin 500 mg four times a day until surgery 6-19-21, medication started 6-12-21 and stopped on 6-19-21. The May 2021 also documented Bactrim DS 800-160 MG for seven days. No physician’s order was provided for the aforementioned medications.
  2. During the exit Staff #1 acknowledged facility did not provide or have physician’s orders for resident #1’s medications.
Plan of correction
• Resident number 1 is no longer in community. Physician orders present in resident record at time of survey. Requesting reconsideration for removal of citation. • The Health & Wellness Director or Designee will provide reeducation on physician’s or other prescriber’s order for current LPNs and RMA’s no later than 3/28/2022. • To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will audit all current resident new physician’s orders and medication records once a month for three months.
22VAC40-73-870-E
Based on observation and staff interview, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by the resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. During a tour of the facility, the vent in the bathroom of room #15 was covered with light grey substance; the bathroom toilet seat and commode is twisted toward the wall; the base of the commode is missing the covering, exposing an approximately 1 in screw. The dresser is missing the front portion of the drawers in room #15.
  2. Staff #1 acknowledged the furnishings and ceiling vent were not in good condition.
Plan of correction
• Resident no longer in community. • Dust removed from bathroom vent, re-caulked around commode on floor and replaced caps to cover screw in room #15. • The Executive Director or Designee will provide reeducation for the housekeeping staff and caregiver staff on reporting maintenance and grounds repairs needed to be completed by 2/15/2022. • The Maintenance staff or designee and care staff will make apartment checks for commode screw caps and bathroom vents for good repair completed by 2/15/2022. • The Maintenance staff or designee and care staff will randomly audit current resident’s commodes for screw caps and bathroom vents for good repair and compliance once a month for three months.
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. Resident #1’s uniformed assessment instrument (UAI) dated 4-9-51 documented wheeling not performed. The ISP dated 4-9-21 documented wheelchair needed as an adaptive equipment. The ISP did not document who and how the services would be provided. Stairclimbing assessed as not performed, the ISP documented resident not able to climb stairs due to unsteady gait; what services would be provided is not documented.
  2. Resident #2’s UAI dated 10-1-21 documented toileting need as mechanical help/physical assistance, walking need as mechanical help/physical assistance, and mobility need as physical and mechanical assistance. The ISP dated 10-1-21 did not identify what specific mechanical assistance was required or needed. A wheelchair and walker were observed in the resident’s room during site visit. Stairclimbing need assessed as not performed. The ISP did not document who and how the services would be provided when needed.
  3. Resident #3’s Active Medication List updated 9-24-21 documented resident allergic to the following: (a) Fenofibrate, micronized (b) Simvastatin and (c) Lisinopril. These medications were not documented on resident’s ISP dated 6-8-21. The UAI dated 6-8-21 documented wheeling and stairclimbing not performed. The ISP did not document what staff would do to provide services. Mobility assessed as mechanical assistance and supervision. The ISP did not document what specific mechanical assistance was required or needed. A wheelchair and walker was observed in resident’s room during site visit.
  4. Resident #4’s UAI dated 10-9-21 documented bathing need as mechanical help and physical assistance. The ISP dated 10-9-21 did not identify what specific mechanical device was required or needed. Stairclimbing assessed as not performed, the ISP did not document how staff would provide services for assessed need.
  5. During exit meetings staff #1 acknowledged all assessed needs for residents #1, #2, #3 and #4 were not documented on the residents’ ISPs.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/30/2021. 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. • Resident number 1 and resident 4 no longer in community. • The Individualized Service Plans (ISP) for Resident number 2 and resident umber 3 will be reviewed by the Executive Director, Health and Wellness Director or Designee and will be updated to reflect current identified needs, services, who will provide services, expected outcomes and completion no later than 12/31/2021. • The Executive Director will provide education for the Health and Wellness Director and Health and Wellness Coordinator on Individualized Service Plans (ISP) compliance by1/31/2022. • The Health and Wellness Director or Designee will audit of all current residents Individualized Service Plans (ISP) for current resident identified needs/services/providers/outcomes and to ensure completion of ISP to be completed by 3/28/2022. • To assist with ongoing compliance, the Health and Wellness Director or Designee will audit three (3) current resident charts Individualized Service Plans (ISP) for identified resident needs and completion of ISP once a month for three months.
22VAC40-73-1140-B
Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment the meets the requirements of subsection C of 22VAC40-73-1140.
Evidence
  1. Staff # 3’s training record documented 9.25 hours of cognitive training, staff’s date of hire documented as 5-21-21.
  2. Staff #4’s training record documented 6.7 hours of cognitive training, staff’s date of hire documented as 5-17-21.
  3. Staff #5’s training record documented 9.25 hours of cognitive training, staff’s date of hire documented as 5-24-21.
  4. During final exit on 11-19-21 staff #1 acknowledged staff did not have the required 10 hours of training in records presented for review.
Plan of correction
• Unable to retroactively correct initial training for Staff number 3 and staff number 4 as were not employed with Brookdale Virginia Beach at time of survey. • Unable to retroactively correct initial training for staff number 5. Training scheduled for staff number 4 - (rehire) and for staff number 5. • The Business Office Manager, Clare Bridge Program Coordinator or Designee will provide training or retraining on Cognitive impairment for staff number 4 and staff number 5 by 2/15/2022. • The Executive Director, Business Office Manager, Clare Bridge Program Manager or Designee will provide reeducation for current direct care associates in regards to cognitive impairments in accordance with VDSS regulations by 3/28/2022. • To assist with ongoing compliance, the Clare Bridge Program Manager or Designee will provide random observations with direct care staff monthly for three months.
22VAC40-73-450-F
Based on record review, staff interview and collateral interview, the facility failed to ensure the resident’s individualized service plan (ISP) was reviewed and updated as the resident’s condition changed .
Evidence
  1. Interview with staff members and collateral interview, stated resident #1’s activities of daily living (ADL) declined after admission to the facility on 4-9-21 and return from hospital. According to interviews, resident was able to walk and was able to go to the bathroom. The resident’s uniform assessment instrument (UAI) and ISP dated 4-9-21 documented resident was independent with toileting, bowel and bladder. According to staff interviews the resident became incontinent of bowel and bladder. Resident’s Progress Notes documented resident’s incontinence and skin breakdown: (a) 5-15-21, “resident now becoming incontinent, resident covered in urine and feces” (b) 6-15-21, “resident fully incontinent” and (c) 6-18-21, “representative notified to provide briefs for incontinent care”. Progress notes documented skin breakdown:(a) 6-13-21, “ an opened area noted on left buttocks and it was bleeding”, during adl care measurements noted and information documented on skin integrity sheet (b) 6-15-21, resident “showing signs of breakdown on bottom (right side)”, resident has “ quarter size reddened area to right buttocks and skin in abraded, notification for home health care” and (c) 6-25-21 “open area on right buttock cheek”.
  2. Resident #1’s June 9, 2021 Order Summary Report documented resident to use wheelchair for ambulation. Resident’s Progress Note documented, (a) 5-20-21, 5-22-21, “resident unable and unwilling to walk to scale” staff requesting an alternate order (b) staff and collateral interviews stated resident’s shortness of breathing made it difficult for resident to walk. The resident physician’s order documented needed Oxygen continuously.
  3. Staff #1 acknowledged resident’s care needs not updated on the UAI and ISP.
Plan of correction
• Resident #1 no longer in community • The Health & Wellness Director or Designee will provide education to LPNs, RMAs, and Caregivers on updating ISP as changes occurs by 1/31/2022. • The Health & Wellness Director or Designee will audit all current resident Individualized Service Plans by 3/28/2022. • To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan chart audits monthly on 3 resident charts for two (2) months.
June 1, 2021Complaint survey2 violations
Inspection dates
June 1, 2021 , June 2, 2021 , June 4, 2021 , June 7, 2021 and June 8, 2021
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 complaint inspection was initiated on 6/1/21 and concluded on 6/8/21. A complaint was received by the department regarding allegations in the area 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 allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-F
Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was updated as needed for a significant change in a resident’s condition.
Evidence
  1. Resident #1’s UAI dated 5/2/21 documented resident needs human-help physical assistance for dressing and transferring; however, ISP dated 10/9/2020 documented resident needs supervision for dressing and is independent with transferring.
  2. Staff #1 acknowledged Resident #1’s ISP dated 10/9/2020 was not updated to reflect current needs for dressing and transferring.
Plan of correction
? The Health & Wellness Director or Designee for resident #1 will review charts and conduct assessments on resident to update changes in resident needs for supervision for dressing and transferring for two weeks until August 81h, 2021 to ensure changes were recorded and changed. ? The Health & Wellness Director or Designee will continue to review ISP policies and to update changes on ISP as they occur. ? To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan chart audits monthly on resident #I for two (2) months ending on September 26, 2021.
22VAC40-73-930-D
Based on record review and interview, the facility failed to make and document rounds no less than every two hours for each resident with an inability to use the signaling device.
Evidence
  1. Resident #1’s current Individualized Service Plan (ISP) dated 10/9/2020 documented due to cognitive impairment, may not remember to use signaling. Staff to provide rounds every two hours when asleep for safety and care needs.
  2. Resident #2’s current ISP dated 11/19/2020 documented resident is unable to use the call light system. Staff will complete visual checks every two hours during hours of sleep for safety and care needs.
  3. Resident #3’s admission date is 5/1/21 and his current ISP dated 5/1/21 documented due to cognitive impairment, may not remember to use signaling. Staff to provide rounds every two hours when asleep for safety and care needs.
  4. Staff #1 could not provide documentation of “VA Night Check and Special Surveillance Record” for resident #1, 2021 resident #2, or resident #3 for the month of May 2021; and acknowledged that documentation could not be provided.
Plan of correction
The following is the Plan of Correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/1/2021. 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. ?The Health & Wellness Director or Designee will ensure that rounds are conducted on resident # l, #2 and #3 ever)' two hours. A two hour check book has been implemented for all residents and staff will conduct the 2 hour checks. Staff will place their initial on the form to ensure the checks were completed. The Health & Wellness Director or Designee will follow up each morning to ensure the two hour checks were completed. ? The ED or designee will do a daily audit to ensure checks are being completed for two weeks until August 8th 2021.
May 4, 2021Inspection2 violations
Inspection dates
May 4, 2021 , May 6, 2021 and May 7, 2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on May 4, 2021 and concluded on May 7, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 26. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, menus, activities calendar, staff schedules, healthcare oversight, health and fire inspections, criminal record and sworn disclosure checks 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
22VAC40-73-320-A
Based on record review and discussion, the facility failed to ensure a person had a physical examination within 30 days preceding admission.
Evidence
  1. Resident #1’s physical examination was dated 11-30-2020; however, the resident admitted 02-18-2021. There was no statement from the physician indicating that there were no changes to the examination.
  2. Staff #1 and staff #2 confirmed during discussion that the physical examination was not within 30 days preceding admission.
Plan of correction
The Executive Director, Sales Manager or Designee will ascertain resident physical examination within 30 days of admission moving forward from 6/3/2021. The Executive Director or designee will provide education for the Sales Manager on resident physical examination prior to admission and Virginia regulations to be complete by 7/30/2021. To assist with ongoing compliance, the Executive Director, Sales Manager or Designee will review all new resident record for physical examination prior to admission and compliance once a month for three months.
22VAC40-73-640-A
Based on record review and discussion, the facility failed to ensure methods that each resident’s prescription medications are refilled in a timely manner to avoid missed dosages.
Evidence
  1. Resident #1’s “Progress Notes” documented the following medications were not refilled in a timely manner to avoid missed dosages 19 times from January 2021 to April 2021: ssed dosages 9 t a. Effexor XR 150 mg: 02-26-2021, 02-27-2021, b. Magnesium Oxide 500 mg: 01-25-2021, 02-07-2021, 02-09-2021, 02-20-2021, 03-06-2021, c. B Complex: 01-27-2021, 01-28-2021, 01-29-2021, d. Pimavanserin Tartrate 34 mg: 02-09-2021, 02-13-2021, 04-17-2021, e. Protonix 40 mg: 02-11-2021, 02-16-2021, f. Aspirin 81 mg: 02-13-2021, 03-12-2021, g. Rasagiline Mesylate: 0.25 mg 02-12-2021, and h. Cholecalciferol Tab 1000u 04-14-2021.
  2. Staff #2 confirmed during discussion Resident #1’s medications were not refilled in a timely manner to avoid missed dosages.
Plan of correction
The Executive Director, Health and Wellness Director or Designee will review medication management plan and implementation no later than 7/12/21. The Executive Director will provide education for Health and Wellness Director and Health and Wellness Coordinator on medication management plan and implementation and Virginia regulations to be complete by 7/12/2021. The Health and Wellness Director or designee will provide education for all RMAs on medication management plan, implementation, and Virginia regulations to be complete by 7/30/2021. The Health and Wellness Director or Designee will audit all medication carts, controlled substance counts, medication administration records and plan for proper disposal of medication and Virginia state compliance to be completed by 7/16/2021. To assist with ongoing compliance, the Health and Wellness Director or Designee will perform random medication management plan and medication cart audits once a month for three months.
March 11, 2021Complaint survey2 violations
Inspection dates
March 11, 2021 , March 12, 2021 , March 13, 2021 and March 16, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on March 5, 2021 and concluded on March 16, 2021. A complaint was received by the department regarding allegations in the areas of medication administration, and resident care. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The complaint is valid.
Violations
22VAC40-73-450-F
Based on record review and discussion, the facility failed to ensure Individualized Service Plans (ISPs) were reviewed as needed as the condition of the resident changed.
Evidence
  1. Resident #1’s Progress Notes from 09-05-2020 to 02-26-2021 documented 13 incidents of combative behaviors, including grabbing staff by the throat and resistance to care.
  2. Resident #1’s current ISP dated 02-28-2021 did not address resident’s combative behaviors.
  3. Staff #1 and staff #2 confirmed Resident #1’s ISP did not address the behaviors mentioned.
Plan of correction
The Health & Wellness Director or Designee has collaborated with resident #1’s Primary Medical Provider and Psychiatric Provider for medication management related to behaviors. The Health & Wellness Director or Designee will reassess and update resident #1’s Individualized Service Plan to reflect behaviors as sited no later than 4/9/2021. The Regional Dementia Care Specialist, Executive Director, Health & Wellness Director or Designee will provide education to all staff regarding Clare Bridge approach and behavioral expressions no later than 6/2/21. To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan chart audits monthly on resident #1 for three (3) months.
22VAC40-73-680-D
Based on record review and discussion the facility failed to ensure medications were administered in accordance with Description: Based on record review and discussion, the facility failed to ensure medications were administered in accordance with the prescriber's instructions.
Evidence
  1. An incident report received by email on 02-13-2021 documented regarding Resident #1, ?While performing routine chart audits, a transcription error was discovered. Error was corrected upon clarification of order. Medication was given 11 days prior to order clarification. Order stated Remeron 30mg QHS [bedtime] but was entered as BID [twice daily] in PCC. [Nurse Practicitioner] aware of transcription error and wrote clarification order...?.
  2. Resident #1’s Medication Administration Record [MAR] documented resident received Remeron 30mg BID from 01-22- 2021 until 02-04-2021. The order was clarified by Nurse Practitioner in Progress Notes dated 02-04-2021, ?It is also noted Remeron was given in error 30mg bid, corrected to @ hs??
  3. Staff #1 and staff #2 confirmed in interview that the aforementioned medication was administered incorrectly for 13 days.
Plan of correction
The Health & Wellness Director or Designee has reviewed and conducted an audit on resident #1’s current medication list. Updated medication orders at time of audit. The Health & Wellness Director or Designee will provide education on Transcription of medication orders to current Registered Medication Aide and License Practical Nurses no later than 6/2/2021. To assist with ongoing compliance, the Health & Wellness Director or designee conduct a medication audit on resident #1’s chart monthly for three (3) months.
November 20, 2020Complaint survey3 violations
Inspection dates
Nov. 20, 2020 , Nov. 23, 2020 , Nov. 24, 2020 , Dec. 3, 2020 and Dec. 4, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 complaint inspection was initiated on 11-20-2020 and concluded on 12-04-2020. A complaint was received by the department regarding allegations in the areas of: Incident Reports; Individualized Service Plans; Provisions for Signaling and Call systems; Personal Care Services and General Supervision and Care, Staffing and Supervision; Food service and Nutrition; and Maintenance of Buildings and Grounds. 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 allegations of non-compliance with standards or law, and violations were issued.
Violations
22VAC40-73-1130-A
Based on record review and interview, the facility failed to ensure when 20 or fewer residents are present, at least two direct care staff members should be awake and on duty at all times in each special care unit who are responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member should be awake and on duty in the unit.
Evidence
  1. Staff #1 stated the total number of residents in care on 09-26-2020 was “25 residents.”
  2. On 09-26-2020, the “September Scheduled 2020” [staff work schedule] (confirmed by Staff #1), documented two direct care staff (Staff #2 and Staff #3) worked from 3:00 p.m. ? 7:00 p.m.
  3. Staff #1 stated a third direct care staff person (Agency Staff #1) worked during the 3:00 p.m. ? 7:00 p.m. shift on 09-26- 20; however, Staff #1 could not provide an invoice documenting the agency staff who worked.
  4. Staff #1 could not provide additional documentation verifying three direct care staff worked on 09-26-2020 from 3:00 p.m. ? 7:00 p.m.
Plan of correction
? The Executive Director, Health and Wellness Director, or Designee will update direct care staffing work schedules to reflect Virginia required staffing ratios for a special care unit by 1/31/2021. ? The Executive Director or Designee will provide education for Health and Wellness Director and Health and Wellness Coordinator on required direct care staffing ratios and Virginia staffing regulations to be completed by 1/31/2021. ? The Health and Wellness Director, Health and Wellness Coordinator, or Designee will review direct care staffing ratios daily for one (1) month for compliance and to identify any potential training opportunities to be completed by 2/28/2021. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director, or Designee will randomly audit direct care staffing ratios and work schedules for compliance with Virginia direct care staffing rations and regulations once a month for three (3) months.
22VAC40-73-290-A
Based on record review and interview, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time, to include any substitutions or other changes noted on the schedule.
Evidence
  1. Staff #1 provided a copy of the staff written work schedules from 08-30-2020 through 10-07-2020. Based on the facility census, the schedules documented two out of three required direct care staff worked from 3:00 p.m. to 7:00 p.m. on 08- 30-2020 and 09-27-2020; and from 11:00 p.m. to 7:00 a.m. on 10-04-2020.
  2. Staff #1 provided documentation from [staffing agency] verifying the agency staff who worked. Staff #1 stated ? Agency Staff #2 worked on 08-30-2020 and 09-27-2020, and Agency Staff #3 on 10-04-2020;? however, the agency staff was not listed on the staff written work schedules.
  3. The staff written work schedules did not document staff person who was in charge on 08-30-2020, 09-27-2020, and 10- 04-2020 during all three shifts.
  4. Staff #1 acknowledged the staff person in charge, substitutions, and other changes were not documented on the staff written work schedules during the aforementioned dates/times.
Plan of correction
? The Executive Director or Designee will provide education for Health and Wellness Director and Health and Wellness Coordinator on Virginia regulations on work schedules and posting of work schedules by 1/31/2021. ? The Executive Director, Health and Wellness Director, or Designee will provide education on work schedules and attendance with current clinical associates by 2/28/2021. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director, or Designee will conduct weekly audits of work schedules for one (1) month then monthly for two (2) months.
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician’s instructions.
Evidence
  1. Resident #5’s current signed physician’s order dated 11-05-2020 documented ?Start E.C Aspirin 325mg one po [by mouth] daily for CVA [stroke] prevention. When new ASA [Aspirin] dose arrives, D/C [discontinue] ASA 81mg.?
  2. Resident #5’s November 2020 Medication Administration Record documented direct care staff administered Aspirin 81mg and Aspirin 325mg on 11-06-2020 through 11-20-2020.
  3. Resident #5’s “Progress Notes” [nursing notes] dated 11-20-2020 documented ?Call placed to [physician] in regards to medication error found. [Physician] made aware that resident had been receiving 81mg aspirin in addition to 325mg aspirin??
  4. Staff #1 acknowledged facility staff did not administer Resident #5’s Aspirin in accordance with the physician’s instructions.
Plan of correction
? The Health & Wellness Director or Designee will provide education on administration of medication and administration in accordance with physician’s orders for current RMA’s no later than 2/28/2021. ? The Health & Wellness Director or designee will review the physician’s orders for resident 5 no later than 2/28/2021. ? To assist with ongoing compliance, the Health & Wellness Director or Designee will audit all current resident new physician’s orders and medication records once a month for three (3) months.
September 30, 2020Complaint survey2 violations
Inspection dates
Sept. 30, 2020 , Oct. 1, 2020 , Oct. 2, 2020 , Oct. 6, 2020 and Oct. 7, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 complaint inspection was initiated on 09-30-2020 and concluded on 10-07-2020. A complaint was received by the department regarding allegations in the areas of Staffing and Supervision, Resident Agreement with Facility and Monthly statement of charges and payments, Personal Care Services and General Supervision of Care, and Individualized Service Plans. The Interim Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Interim Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-40-A
Based on record review and interview, the licensee failed to ensure compliance with the facility’s policies and procedures.
Evidence
  1. Staff #1 provided the “Residency Agreement” for resident #2 (dated 12-08-2016), resident #3 (dated 11-25-2019); and resident #4 (dated 12-27-2017) which documented ?? Rate Changes. We will provide thirty (30) days written notice of any change in the rates or pricing method for Basic Services, Personal Services, Select Services, and Therapeutic Services. We may offer or require a change in Personal Service Plan when we determine additional services are requested or required. The new Personal Service Rate resulting from a change in your Personal Services Plan is effective immediately after written notice is given??
  2. Staff #1 provided copies of resident #2, resident #3, and resident #4`s July, August, and September 2020 monthly billing statements. The billing statements documented an increase in rates for Personal Care Services: A. Resident #2’s July 2020 statement documented a “Personal Service Rate” of $3,506.00. The August 2020 statement and September 2020 statement documented a “Personal Service Rate of $3,980.00.” B. Resident #3’s July 2020 statement documented a “Personal Service Rate” of $1,885.00. The August 2020 statement and September 2020 statement documented a “Personal Service Rate of $3,419.00.” C. Resident #4’s July 2020 statement documented a “Personal Service Rate” of $3,496.00. The August 2020 statement and September 2020 statement documented a “Personal Service Rate of $3,555.00.”
  3. When asked to provide documentation of the written notice of changes in the rates or pricing for Personal Services to Residents #2, #3, and #4’s or to their legal representative, staff #1 stated the changes were noted on the Residents Individualized Service Plans (ISP’s). Resident #2’s current ISP dated 07-28-2020, Resident #3’s current ISP dated 08-25- 2020, and Resident #4’s current ISP dated 08-31-2020 did not document changes in the rates or pricing for Personal Services.
  4. Staff #1 could not provide documentation of a 30 day written notice of any change in the rates or pricing method for Basic Services, Personal Services, Select Services, and Therapeutic Services for Residents #2, #3, or #4.
Plan of correction
? The Executive Director or Designee will provide retraining to Business Office Manager and Health & Wellness Director on process of written notification to the resident/legal representative of rate or pricing method change for Basic Services, Personal Services, Select Services, and Therapeutic Services. ? The Business Office Director or Designee will maintain documentation in resident records of written notification given of any rate or pricing method change for Basic Services, Personal Services, Select Services and Therapeutic Services. ? To assist with ongoing compliance, the Executive Director or Designee will audit random resident records to ensure written notification is given with any change in the rates or pricing method for Basic Services, Personal Services, Select Services and Therapeutic Services once a month for three (3) months.
22VAC40-73-460-D
Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs to prevent wandering from the premises.
Evidence
  1. On 09-15-2020, staff #1 emailed an incident report involving resident #1’s elopement from the special care unit. The incident report documented ?Resident was noted outside of the building off of the property [on 09/14/2020 at approximately 12:50 PM]. Elopement protocol implemented and resident found by staff without injury.?
  2. The facility’s “Incident Investigation” form dated 09-14-2020 documented ?1:10pm- med tech could not locate resident #1; 1:32- Resident located at a [local] pizza restaurant and had arrived at approximately 1 pm?? Additionally, Resident #1’s “Progress Notes” dated “09/14/2020” documented ?Resident left the building around 1 ish, he was found at the [local] pizza restaurant for 45 mins?? The distance from the facility to the local pizza restaurant is approximately 0.1 miles; and the roads that surround the facility are: Diamond Springs Road and Wesleyan Drive with a speed limit range of 35 mph to 45 mph.
  3. Additional documentation reviewed documented resident #1’s wandering behaviors: A. An incident report dated 06-25-2020 documented ?Resident wandered on toward sidewalk in front of community [on 06-24-2020 at approximately 11:15 AM]. Staff immediately went to resident, assessed resident for c/o and injuries - no injuries, all exit doors are being evaluated by maintence.? B. Resident #1’s Uniform Assessment Instrument (UAI) dated 06-24-2020 (and updated on 09-14-2020) documented the resident has wandering behaviors weekly or more and “exhibits exit seeking behaviors.”
  4. Staff #1 acknowledged that ?resident #1 had wandering/exit seeking behaviors on the UAI prior to the elopement incident on 09-14-2020.?
Plan of correction
? The Executive Director or Designee will provide retraining on reducing the risk of elopement to current clinical staff no later than 3/15/2021. ? The Health & Wellness Director or designee will review UAI of current residents to identify residents with wandering or exit seeking behaviors no later than 3/15/2021. ? The Executive Director or Designee hired and trained day shift receptionist in November 2020. This has made a positive impact for the residents and community. ? To assist with ongoing compliance, the Maintenance Director or Designee will conduct elopement drills for each shift once a month for three (3) months.