VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Harrisonburg
2101 Deyerle Avenue
Harrisonburg, VA 22801
(540) 574-2982

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: May 21, 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.

Technical Assistance:

The administrator reported that aggressive resident training is being conducted by a Certified Recreational Therapist. Standard 270.3.a. requires that the aggressive resident training be conducted by a qualified health professional. The intention of this requirement is that the trainer be a R.N., L.P.N., psychologist, social worker, counselor, or other health professional who has knowledge of and experience working with people with aggressive behaviors. This professional does not have to be licensed but does have to be trained as a trainer using an aggressive behavior curriculum. A large water stain was observed on the ceiling in the memory care unit just outside of the sitting area. A copy of an email that the administrator provided shows that repairs are being arranged for the water stained area. Staff purses and personal items were observed in the unlocked staff break room in unlocked lockers. It is recommended that these items be secured in a locked area, for resident safety and staff personal item protection. As a reminder, one serving of fruit juice per day can be counted toward the required number of servings of fruit each day. If fruit juice is served at breakfast the juice can be counted as a serving. Also, snacks can be incorporated into the number of recommended servings as long as all residents are aware that the snacks are available.

Comments:

A monitoring visit was conducted at Brookdale Harrisonburg by an LI from the Piedmont Licensing office on 5/21/19 from 9:30am until 3:00pm in conjunction with the LA from the Piedmont Licensing office and a consultant. Resident and staff records as well as other forms of facility documentation were reviewed. A tour of the facility physical plant was conducted and interviews were obtained from residents and staff. The 11am medication pass and mid-day meal were observed. An exit interview occurred on site with the facility administrator at the end of this inspection. Please respond back with a plan of correction within 10 days of receipt of this violation notice. If you have any questions please feel free to contact the LI 540-309-2968.

Violations:

Standard #:	22VAC40-73-270-1
Description:	Based on documentation review and staff interview, the facility failed to provide aggressive resident training to include all of the required components. EVIDENCE: 1. The documented aggressive resident training does not indicate that the training includes demonstration and practical experience in self-protection and in the prevention and de-escalation of aggressive behaviors. 2. The administrator and director of nursing both verified that the aggressive training provided by the facility does not include a hands-on aspect of training.
Plan of Correction:	? Unable to retroactively correct training not completed, training will be conducted by the Executive Director / designee to meet the aggressive resident training standard no later than June 22nd, 2019. ? The HWD and RCC will be re-educated by the Executive Director/designee on the required aspects of this aggressive resident training to include at a minimum; information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior. ? Current direct care associates, and any direct care associates hired after June 6th, 2019, will be retrained by the Executive Director / designee in methods of caring for residents who have a history of aggressive behavior or of dangerously agitated states, including demonstration and practical experience in self-protection and in the prevention of de-escalation of aggressive behavior no later than June 30th, 2019. ? To assist with ongoing compliance, associate training requirements will be monitored by the ED/BOC or designee weekly for eight (8) weeks.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record reviews, the facility failed to ensure that all personal and social information was obtained as required. EVIDENCE: 1. The personal and social information form i the record for residents 12 and 15 were incomplete as they lacked information on the residents current behavioral and social functioning including strengths and problems.
Plan of Correction:	? Personal and Social information forms for resident #12 and #15 were completed to include all information on June 3, 2019. ? The HWD, RCC and BOC were reeducated by the Executive Director on June 6th, 2019, on the need for the personal and social information to be completed in its entirety before filing into resident chart. ? Beginning June 1, 2019, for one (1) month, the Executive Director/ BOC or designee will review all new resident`s personal and social data forms to ensure they are complete before being filed in the resident chart. ? Thereafter to assist with ongoing compliance, the ED or designee with review new move in personal and social data forms for completeness weekly for eight (8) weeks.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record reviews and interviews with staff, the facility failed to ensure that uniform assessment instruments were completed as required. EVIDENCE: 1. The most recent uniformed assessment instrument (UAI) for resident 16, dated 4/24/2018, had not been updated within the past twelve months. 2. Interview with staff person 6 revealed that resident 2 has been using a wheelchair for over a month and needs physical assistance with wheeling. The UAI, dated 4/9/2019, has not been revised to show the resident requires help with wheeling. 3. The UAI for resident 14, dated 4/19/2019, shows the resident requires only mechanical help with mobility; however, this resident has a serious cognitive impairment and resides is a safe, secure unit. The UAI shows the resident is independent with dressing; however, interview with staff person 7 reveals the resident requires physical assistance with dressing. This UAI shows the resident requires only supervision with bathing; however, interview with staff person 7 reveals the resident requires physical assistance with bathing. 4. The UAI for resident 15, dated 2/8/19, shows the resident requires physical assistance with dressing and mechanical and physical assistance with toileting. An interview with staff person 6 reveals that the resident requires supervision only with dressing and only mechanical assistance with toileting.
Plan of Correction:	? The UAI(s) for residents 2, 14, 16 and 15 will be updated to reflect the resident?s accurate needs by June 10, 2019. ? The Executive Director/designee will reeducate the Health and Wellness Director and Resident Care Coordinator on Uniform Assessment Instruments no later than June 10, 2019. ? Beginning June 10, 2019, all resident UAIs will be reviewed by the Executive Director/Health and Wellness Director/Resident Care Coordinator designee to verify the completeness UAI(s) and that the UAI includes accurate information. ? Thereafter, to assist with ongoing compliance, new admissions and residents that require re-assessments will have their UAI(s) reviewed for accurateness weekly for eight (8) weeks by the Executive Director/Health and Wellness Director/Resident Care Coordinator/designee.
Standard #:	22VAC40-73-450-C
Description:	Based on a resident record reviews and interviews with staff, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The UAI for resident 14, dated 4/19/2019, shows the resident is independent with toileting, which was confirmed via interview with staff person 7; however, the comprehensive ISP shows the resident needs mechanical help with toileting. 2. The UAI for resident 2, dated 4/9/2019, shows the resident needs mechanical and physical assistance with toileting, which was confirmed by staff person 6; however, the comprehensive ISP shows the resident requires only mechanical assistance. 3. The UAI for resident 15, dated 2/8/19, shows the resident needs supervision with bathing, physical assistance with stair climbing and mechanical and physical assistance with mobility which was confirmed by staff person 6; however the comprehensive ISP shows the resident requires mechanical and physical assistance with bathing, supervision and mechanical assistance with stair climbing and mechanical assistance only with mobility.
Plan of Correction:	? The UAI for residents # 14, #15 and #2 will be updated to reflect accurate information no later than June 10, 2019 ? The Executive Director/ designee will reeducate staff members certified to complete UAI(s) and ISP(s) on accuracy no later than June 10th, 2019. ? Beginning June 10, 2019, all resident UAIs will be reviewed by the Executive Director/Health and Wellness Director/Resident Care Coordinator designee to verify the completeness UAI(s) and that the UAI includes accurate information. ? Thereafter, to assist with ongoing compliance, new admissions and residents that require re-assessments will have their UAI(s) reviewed for accurateness weekly for eight (8) weeks by the Executive Director/Health and Wellness Director/Resident Care Coordinator/designee.
Standard #:	22VAC40-73-450-F
Description:	Based on review of resident records, the facility failed to update an individualized service plan (ISP) as the condition of the resident changed. EVIDENCE: 1. The ISP for resident 2, dated 8/16/2018, indicates the resident is at a high risk for falls. The resident has fallen numerous times since the date of the ISP; however, the facility has not revised the fall prevention program. The most recent fall resulted in a fracture of the left humerus.
Plan of Correction:	? Resident #2 will have an updated ISP by June 10th, 2019. ? Reeducation will be conducted by the Executive Director /designee to the Health and Wellness Director and Resident Care Coordinator no later than June 10th, 2019. ? Residents with an acute decline will be reassessed immediately by the staff certified to complete the UAI(s) and ISP(s) to verify all needs are addressed and documented on the UAI and ISP. ? The HWD/RCC/designee will provide any resident declines in our morning meeting, and this will be followed up by a chart review by the HWD/RCC/designee the same day to verify the resident?s needs are being addressed. ? UAIs and ISPs will be audited weekly by the Executive Director/designee for the next eight (8) weeks. ? Thereafter, to assist with ongoing compliance the Executive Director/designee will conduct monthly audits of ISPs and UAIs for three months (3) to verify completeness.
Standard #:	22VAC40-73-520-I
Description:	Based on documentation review, the facility failed to include on the written posted activity calendar the hour of the activity that was scheduled. EVIDENCE: 1. The posted May activity calendar only included a start time on scheduled activities. An end time was not included and there was no written statement on the calendar indicating the length of each activity.
Plan of Correction:	? Unable to retroactively correct the May or June activity calendars. ? The July activity calendar will include a statement on the calendar indicating the length of each activity. ? Reeducation will be conducted by the Executive Director to the Programming Coordinator no later than June 6th, 2019, on activity calendars. ? The programming coordinator for Assisted Living and our Memory care will correct the July activity calendar and all activity calendars going forward. ? To assist with ongoing compliance, the Executive Director will audit the monthly activity calendars monthly for two (2) months to verify the statement indicating the length of each activity is included on the calendar.
Standard #:	22VAC40-73-610-B
Description:	Based on documentation review and observations made during the morning tour of the building, the facility failed to post correct snacks for the current week. EVIDENCE: 1. The posted menu stated that only mid evening snacks were available instead of being available at all times. The posted snack offered for Tuesday, May 21, 2019 was Granola Bar. However, bananas and cookies were sitting out in a basket in the dining room.
Plan of Correction:	? A snack menu with snacks available at any time was posted by the Executive Director on May 28, 2019, by the menu postings. ? Reeducation conducted by the Executive Director to the Dining Director regarding consistent posting of the snack menu in conjunction with the daily menus moving forward. ? To assist with ongoing compliance the snack menu will remain posted outside of the dining room and will be audited daily for two (2) months by the Executive Director/ designee.
Standard #:	22VAC40-73-620-B
Description:	Based on documentation review and interview, the facility failed to ensure that the requirements of the oversight of special diets were met. EVIDENCE: 1. The dietician report provided by the facility, dated 3/15/2019, did not include verification that the physician?s orders were reviewed or the signature of the dietitian.
Plan of Correction:	? The report from the Registered Dietician was electronically emailed after the review. ? It was confirmed by the Executive Director on May 21st, 2019 that the Registered Dietician reviews special diets during visits. ? Residents on special diets have handwritten notes and the signature of the reviewing dietician in the resident?s medical file under the dining tab, the Executive Director/designee will audit the nutrition tracker weekly for two (2) months, the information will be given to the Registered Dietician upon arrival to the community to verify new residents with a special diet have been reviewed and all special diets are reviewed every six (6) months. ? To assist with ongoing compliance the Executive Director/Health and Wellness Director/designee will audit the Nutrition Tracker monthly for three (3) months to verify residents on special diets with Registered Dietician oversight have documentation under the dining tab.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication carts, the facility failed to implement their medication management in regards to methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. Lantus Insulin with an open date of 4/9/19 was noted to be on the medication cart and in use for resident 8. Manufacturer guidelines are to discard this medication 28 days after opening, therefore this medication should have been removed from use no later than 5/6/19. 2. Lantus Insulin with an open date of 4/19/19 was noted to be on the medication cart and in use for resident 2. Manufacturer guidelines are to discard this medication 28 days after opening, therefore this medication should have been removed from use no later than 5/16/19. 3. Latanoprost Opth Sol 2.5ml with an open date of 3/17/19 was noted to be on the medication cart and in use for resident 9. Manufacturer instructions are to discard this medication 42 days (6 weeks) after opening, therefore this medication should have been removed from use no later than 4/27/19. 4. The facility medication management plan has documentation that weekly medication cart audits are completed by the HWD/RCC or designee to remove expired and discontinued medications.
Plan of Correction:	The following is a summary of the Plan of Correction for Brookdale Harrisonburg. This Plan of Correction is in regards to the Corrective Action Report dated May 21, 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 expired Lantus insulin and Latanoprost Opthalmic drops were removed from the medication cart immediately 5/21/2019, the day of inspection, and new supplies ordered from the pharmacy ? Medication carts will be audited by the Health and Wellness Director/designee, by June 14, 2019, to verify medication?s that have manufacturer?s guidelines for discarding after opening, are not expired. ? Registered Medication Aides and Licensed nurses will be educated by June 14, 2019, by the Health and Wellness Director / designee on putting an open date as well as a discard date on insulin and ophthalmic drops to verify they are not being administered past the manufacturer?s guidelines. ? To assist with ongoing compliance, the HWD/RCC or designee will complete a medication cart audit weekly, beginning June 14, 2019, for four (4) weeks to verify there is no expired insulin or ophthalmic drops located on the cart.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record reviews and interviews with staff, the facility failed to administer medications in accordance with physician instructions. EVIDENCE: 1. The May 2019 medication administration record (MAR) for resident 10 has a physician order for Cyanobalamin 1000mcg/ml, 1 ml intramuscularly every month on the 19th. The MAR did not have staff initials for the administration of this mediation on 5/19/19. The LI observed a bottle of Cyanobalamin 1000mcg/ml for resident 10 in the medication cart with a pharmacy delivery dated of 4/19/19. Interviews with staff persons 1 and 2 reveals that the medication had not been administered on 5/19/19 as ordered because a licensed health care professional was not in the building to administer it.
Plan of Correction:	? The Vitamin B12 injection for resident 10 was administered the day of inspection, May 21, 2019. ? Injections that need to be administered by a licensed nurse will be reviewed by the Executive Director (ED) by June 7, 2019, to verify they have been administered as ordered by the PCP. ? New orders obtained by the HWD from the Physician will be administered pursuant to the Physicians orders. ? To assist with ongoing compliance the Executive Director or designee will monitor medications that are required to be administered by a licensed nurse for six (6) months to verify they are being administered as ordered.
Standard #:	22VAC40-73-860-I
Description:	Based on observations and staff interviews, the facility failed to store all cleaning supplies and hazardous materials in a locked area. EVIDENCE: 1. An unattended unlocked cleaning cart on the memory care unit contained a pair of pliers and a screwdriver in a hanging caddy on the side of the cleaning cart. 2. The unlocked unattended housekeeping storage room across from the kitchen contained Orange force multi surface cleaner; Antibacterial cleaner; Rinse Additive; three gallons of paint; Medallion Stainless Steel cleanser; Peroxide Multipurpose cleanser; two gallons of Lime Away; Spray Stainless Steel cleaner; Sanitizing Wash N Walk; Miracle Spotter; Grease & Oil Spotter; Biological Spotter & Odor Eliminator. The Director of Nursing observed the housekeeping storage room to be unlocked along with the inspector. 3. A spray can of Acrylic Sealer & Gloss Finish was sitting on a column in the outdoor sitting area on the Assisted Living side of the building. The facility houses a mixed population of residents on the Assisted living side of the building.
Plan of Correction:	? The pliers and screwdriver on the cleaning cart were placed inside the cart and the cart was immediately locked. The housekeeping closet across from the kitchen was immediately locked when found to be unlocked. The Acrylic Sealer and Gloss Finish on the patio was immediately removed and properly secured. ? Closets containing chemicals was observed by the maintenance manager to be secured. The housekeeper was in-serviced immediately on May 21, 2019 by the Executive Director, that if the housekeeping cart was not within arm?s reach, it must remain locked and all chemicals and tools would remain secured as well. A new automatic locking mechanism has been placed on the closet door. ? All Associates will be re-educated on safe storage of chemicals by the Executive Director/designee no later than June 22, 2019. ? The Executive Director / designee will conduct daily audits for two (2) months to verify that housekeeping carts are locked and all chemicals, tools and supplies are secure. ? To assist with ongoing compliance, The ED/designee will conduct monthly checks to verify the housekeeping carts are locked and secured for three (3) additional months.
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to maintain all furnishings and fixtures in good repair and condition. EVIDENCE: 1. The bi-fold closet door in memory care resident room # 204 was observed to be off the top track, hanging down and sitting on the floor. The door was difficult to open due to dragging on the carpeted flooring. 2. The bi-fold closet door in memory care resident room # 203 was observed to be hanging off the track. 3. The plastic covering on the box spring on the bed in memory care resident room # 217 was observed to have a large spit extending all the way around the left corner.
Plan of Correction:	? The bi-fold closet door in room 204 and 203 were repaired the day of inspection, May 21, 2019. The box mattress in room 217 was replaced the day of inspection. ? Direct care, housekeeping and maintenance associates will be reeducated on June 21, 2019, on the repair of any furnishings or fixtures which are not in good repair, and to inform the Maintenance manager to be repaired or replaced. ? The BOC/designee will be placing a maintenance log in both nursing offices for staff to document issues with furnishings and fixtures by June 21, 2019. ? To assist with ongoing compliance, the Maintenance Manager/designee will check the maintenance log each day and repair or replace items as needed.
Standard #:	22VAC40-73-950-C
Description:	Based on documentation review, the facility failed to ensure semi-annual reviews on the emergency preparedness and response plan were conducted with all staff. EVIDENCE: 1. The facility conducted a review of the emergency preparedness and response plan with staff on 2/13/2018. The next review was not conducted until 3/26/2019 and twelve facility staff did not participate in this review.
Plan of Correction:	? We are unable to retroactively correct missing emergency preparedness training with associates. ? Associates will receive emergency preparedness training by the Executive Director/designee before June 30, 2019, and every six (6) months thereafter. ? The Executive Director/Business Office Coordinator/designee will audit the next two (2) trainings to verify all associates received the training. ? To assist with ongoing compliance the Executive Director/designee will report monthly for two (2) months, to the District Director of Operations with verification that staff training has been completed.