VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Roanoke
1127 Persinger Road, S.W.
Roanoke, VA 24015
(540) 343-4900

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: April 8, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

The LI for Brookdale Roanoke conducted unannounced monitoring visit at the facility on 4/8/19 from 8:30am until 1:00pm in conjunction with another LI and noted 51 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed. A tour of the facility physical plant was conducted and the mid day medication pass and meal were observed. Interviews were conducted with residents and staff. The LI discussed with the facility administrator standard 390-A, ensuring that all required information is included in the body of resident agreements and standard 870-A, preventative maintenance for maintaining the interior of the building in good repair. Please respond back with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-390-C
Description:	Based on a review of resident records, the facility failed to update resident agreements when changes in policies and other information occurred. Evidence: 1. The records for residents 1, 2, 3, 4, 5, 9 and 10 were all noted to contain an outdated resident agreement, which did not include information required by the new regulations that were effective 2/1/2018.
Plan of Correction:	The following is a summary of the Plan of correction for Brookdale Roanoke. This Plan of correction is in regards to Violation Notice dated April 04 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 Residency Agreement System has been updated to reflect the new regulation. Executive Director or designee will meet with the residents and/or responsible parties in an order to update resident files with new residency agreements to reflect the new regulation. An audit of Residency Agreements will be completed weekly times 8 weeks by the Executive Director or designee to monitor for ongoing compliance. The Executive Director /Designee will be responsible for directing additional corrective actions, as needed, based on audit findings.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record reviews, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The record for resident 4 has documentation on several dates from 3/10/19 through 4/5/19 of the resident displaying aggressive and combative behavior. The UAI dated 1/25/19 has the residents behavior assessed as wandering and does not include the residents aggressive/combatitive behaviors.
Plan of Correction:	? Resident 4: UAI has been updated to reflect aggressive/combative behaviors. An audit of other residents? UAIs was completed by the Health and Wellness Director (HWD) /Designee to determine if other residents with behaviors were affected, and to update the UAI as necessary. Training was conducted by the Executive Director / Designee, to UAI certified staff members, on 4/23/19 to train on the appropriate components of a Uniform Assessment Instrument. The Health and Wellness Director (HWD) and /or designee will complete a UAI Audit weekly for the next 8 weeks, to monitor compliance. HWD or designee will complete unannounced monthly audits of Individual Service Plans to verify ongoing compliance. The ED/ Designee will direct additional corrective actions, as determined by audit findings.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record reviews, the facility failed to ensure that all identified needs were addressed on comprehensive individualized service plans (ISPs). EVIDENCE: 1. The record for resident 2 has a physician order dated 4/2/19 for a regular-gluten free diet. The comprehensive ISP dated 2/26/19 has that the resident is on a regular diet and does not address the identified need for gluten free foods. 2. The UAI for resident 9, dated 11/23/2018, shows this resident is disoriented to all spheres all the time, and the comprehensive ISP does not show what needs are given to resident 9 for this problem. 3. The UAI for resident 10, dated 11/10/2018, shows this person is disoriented to all spheres, all the time, and the comprehensive ISP, dated 11/29/2019, does not show what services are given to resident 10 for this problem.
Plan of Correction:	? ISPs for residents 2, 9, and 10 have all been updated by the HWD / Designee to verify current needs are addressed in the plan. An audit of other residents? ISPs was completed by the Health and Wellness Director (HWD) /Designee to determine if other residents were affected, and to update the UAI as necessary. Training was conducted by the Executive Director / Designee, to UAI/ISP certified staff members, on 4/23/19 to train on the appropriate components of a Uniform Assessment Instrument/ISP. The Health and Wellness Director (HWD) and /or designee will complete a UAI Audit weekly for the next 8 weeks, to monitor compliance. HWD or designee will complete unannounced monthly audits of Individual Service Plans to verify ongoing compliance. The Executive Director/Designee will be responsible for directing additional corrective action, based on audit findings.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to include hospice services on a comprehensive individualized service plan (ISP). EVIDENCE: 1. The comprehensive ISP, dated 11/29/2018, for resident 10 shows that this resident receives hospice services, but the ISP does not include what services hospice is providing.
Plan of Correction:	? The ISP for resident 10 has been updated to reflect detailed hospice services. An audit of other residents? ISPs was completed by the Health and Wellness Director (HWD) /Designee to determine if other residents with behaviors were affected, and to update the UAI as necessary. Training was conducted by the Executive Director / Designee, to UAI/ISP certified staff members, on 4/23/19 to train on the appropriate components of a Uniform Assessment Instrument. The Health and Wellness Director (HWD) and /or designee will complete a UAI Audit weekly for the next 8 weeks, to monitor compliance. HWD or designee will complete unannounced monthly audits of Individual Service Plans to verify ongoing compliance. The Executive Director/Designee will be responsible for directing additional corrective action, based on audit findings.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to obtain required signatures and dates on a comprehensive individualized service plan (ISP). EVIDENCE: 1. The comprehensive ISP for resident 9, with needs identified on 11/23/2018, is lacking all required signatures, and the date the comprehensive ISP was completed was not noted.
Plan of Correction:	? The ISP for resident 9 has been dated for completion. An audit of other residents? ISPs was completed by the Health and Wellness Director (HWD) /Designee to determine if other residents with behaviors were affected, and to update the UAI as necessary. Training was conducted by the Executive Director / Designee, to UAI/ISP certified staff members, on 4/23/19 to train on the appropriate components of a Uniform Assessment Instrument/ ISP, and the need for signatures. HWD or designee will continue to audit and contact Power of Attorney in order to get signatures at all updates. A notation will be included for efforts made to contact and attain dates and signatures. ED or designee will complete audit for signature compliance for the next 8 weeks, in order to maintain ongoing compliance a random monthly audit will be completed. The Executive Director/Designee will be responsible for directing additional corrective action, based on audit findings.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to implement their medication management plan in regards to the methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The Controlled Substance/MAR Change of Shift Audit sheets for April 2018 are missing at least one section of the form on April 1 through 8, 2019. Various missing sections: off-going staff signature, on-coming staff signature, count is correct Y/N, number of controlled substance sheets ? no counts.
Plan of Correction:	? The controlled substance/MAR Change of shift forms are unable to be corrected retroactively. HWD will in-service all medication staff on the medication management plan/proper documentation and the policy related to the controlled substance log. This training will be conducted on 5/2/2019. HWD or designee will complete a weekly shift change audit for the next 8 weeks. A monthly audit will be completed to monitor for ongoing compliance of the controlled substance log. Results of audits will be provided to the ED/Designee. The ED/Designee will direct additional corrective action, when needed, based on audit findings.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure all required information was included on resident medication administration records (MARs). EVIDENCE: 1. The April 2019 MAR for resident 2 does not have staff initials for 2 hour checks being made at 2pm on 4/5/19. 2. THe March 2019 MAR for resident 11 does not have staff initials for the administration of the prescribed medication Atorvastatin Calcium 10mg daily at 8pm on 3/10/19.
Plan of Correction:	? Unable to correct resident 2 or resident 11 MAR retroactively HWD or designee will re-educate staff administering medications to include Medication Management Plan and Documentation. This training will be completed on 5/2/2019. HWD or designee will complete MAR audit to monitor for holes daily. ED or designee will complete a weekly MAR audit to monitor for compliance for the next 8 weeks. Unannounced monthly audits will be completed by the ED or HWD designee to monitor for ongoing compliance for medication administration documentation.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to obtain a complete order for oxygen. EVIDENCE: 1. The oxygen order for resident 9 is lacking the source of the oxygen.
Plan of Correction:	? The oxygen order for resident 9 has been updated to reflect source of oxygen. Because other residents have the potential to be affected, all residents receiving oxygen therapy were reviewed to verify their physician orders reflect oxygen and the source. Training to be completed by the HWD on 5/2/2019 to staff responsible for completing physician orders for oxygen administration, to include the source of oxygen. HWD or designee will audit times 8 weeks to ensure all oxygen orders have documentation for the required information. ED or designee will complete unannounced monthly audits of oxygen orders for compliance in order to maintain ongoing compliance.
Standard #:	22VAC40-73-970-E
Description:	Based on document review, the facility failed to ensure that all required information was included on the facility fire drill log. EVIDENCE: 1. The facility fire drill log for January, February and March 2019 did not contain the method used for notification of the drill or any special conditions simulated.
Plan of Correction:	? Unable to retroactively correct fire drill forms for January, February or March. The Maintenance Manager will receive re-education from the Executive Director/Designee on 4/29/2019. This training will include the requirements related to documentation of fire drills as well as the required schedule for fire and emergency evacuation drills. Maintenance Manager will begin using the fire drill form from the DSS web site to document all required information for fire drills is included on the form. ED / Designee will audit fire drill forms monthly to ensure documentation is complete. The ED / Designee will be responsible for directing additional corrective action, based on audit findings.