VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 26, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This was an unannounced Renewal Inspection conducted by Licensing Inspectors from the Eastern Regional Office. This Inspection was conducted on 04/26/2019 ( 8:15 a.m. - 2:56 p.m.) During the inspection a medication observation was conducted, a tour of the facility and staff and resident records were reviewed. Licensing Inspector conducted staff and family's interviews. The Healthcare Oversight Report, Emergency Evacuation Drills, Fire Inspection, Health Inspection, and Emergency Preparedness and Response Plan were reviewed during the inspections. There were 44 residents in care during the inspection. There were violations cited in the area of Resident Care and Related Services. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain 1.) Steps to correct the noncompliance with standards (s) 2.) Measure to prevent the noncompliance from occurring again; and 3.) Person (s) responsible for implementing each step and/ or monitoring any preventive measures (s). Please send your corrective plan to me in a Word Document by 05/16/2019 or sooner. Thank you.

Violations:

Standard #:	22VAC40-73-450-B
Description:	Based on record review and interview the facility failed to develop a comprehensive individualized service plans ( ISP) that met the resident's service needs as required by the department approved ISP training. Evidence: 1.Resident # 1's Uniform Assessment Instrument (UAI) dated 11-27-2018 indicated resident does not need assistance with stairclimbing or mobility, while resident # 1's Individualized Service Plan ( ISP) dated 10-18-2018 indicated resident does not perform stairclimbing, and uses a cane or walker for mobility. Staff # 2 acknowledged that # 1 can ambulate stairs but does not due to lack of stairs in facility, and does not use adaptive equipment to ambulate. 2. Resident # 1's ISP indicates the resident does not use psychotropic medications. However, resident # 1 was prescribed benzodiazephine medication which was listed on resident's Medication Administration Record (MAR) and Personal Service Plan. Staff # 2 confirmed resident does take benzodiazepine medications. 3. Resident # 2's UAI dated 10-03-2018 indicated resident requires mechanical and human help physical assistance with use of hand rails while toileting while resident?s ISP dated 03-19-2019 does not indicate resident requires mechanical help or hand rails. LI observed on 04-26-2019 at 1:28 p.m. that resident # 2 had a raised toilet seat and hand rails. Staff # 2 confirmed resident # 2 does require mechanical assistance while toileting. 4. Resident # 3's ISP dated 09-18-2018 indicated that client is on a texture modified soft-solid diet and requires mechanical help with eating with use of a geriatric cup and plate guard. LI observed during lunch resident # 3 was eating without use of a geriatric cup or plate guard, and observed resident?s relative was feeding her. Staff # 2 acknowledged that resident no longer requires mechanical assistance eating due to staff providing physical assistance for client to eat and that resident?s relative sometimes feeds client this information was not reflected on the ISP. 5. LI reviewed the above with staff # 1 during the inspection.
Plan of Correction:	The following is a summary of the Plan of Correction for Brookdale Virginia Beach. This Plan of Correction is in regards to the Violation Notice dated April 26 th , 2019. 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. The Individual Service Plan and Uniform Assessment Instrument has been updated by the Health and Wellness Director (HWD)/ Designee to reflect accurate stairclimbing, mobility and adaptive equipment. The affected resident was re-evaluated by the HWD for the use of benzodiazapines. (See Anti-Psychotic and Benzodiazapine Medication Review). The Individual Service Plan has been updated to address the use of a benzodiazepines, its potential side effects, efficacy, and reason for continued use. The Individual Service Plan has been updated for resident #2 to reflect the need for mechanical as well as physical assistance, which includes the use of handrails while toileting, and the use of a raised toilet seat. The Individual Service Plan for resident #3 has been updated to reflect the family assisting the resident with feeding, at times, while staff promotes independence in picking up her own rolls and sandwiches. The plate guard and geriatric cup will continue to be used as the resident requires or needs. Other residents have the potential to be affected by the alleged deficient practice. Current residents will be reviewed during the community?s Collaborative Care Review Process to identify changes in condition and updates requiring inclusion in the resident?s ISP and UAI. The HWD/Designee will be responsible for updating accordingly, but no later than 5/21/19. 2). The District Director of Clinical Services will re-educate the Health and Wellness Director and current certified staff in completing Individual Service Plans and Uniform Instrument Assessment no later than May 10 th , 2019. 3). An audit of current Uniform Instrument and Individual Service Plans will be completed monthly times two months by the Health and Wellness Director/ designee to monitor for accuracy in assessments. Additional reviews will be based on audit findings.