VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Salem
2001 Ridgewood Drive
Salem, VA 24153
(540) 494-8594

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: May 29, 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 facility received technical assistance on the following: 1) completing documents to include dates and all blanks; and 2) 1140B - 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.

Comments:

Two LIs completed the renewal inspection, which resulted in 17 violations. At 8:54 am, the inspection commenced and concluded at 3:28 pm. During the inspection the following was reviewed: physical plant walk through; 10 residents and 6 staff records' review; medication pass observation; and interviews. After completing the inspection, the facility staff and LIs discussed the violations, possible corrective actions and had an open discussion. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector 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 the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on resident record review, the facility failed to obtain an assessment of serious cognitive impairment from a physician prior to admitting a resident to a safe secure unit. Evidence: 1. Resident 1did not have documentation indicating an assessment of serious cognitive impairment was completed by a physician prior to admittance to the safe, secure unit on 4/1/19.
Plan of Correction:	1). Resident #1 has documentation of a serious cognitive impairment for residing on the memory care secure unit. 2). The Executive Director/ designee will retrain the Health and Wellness Director, Resident Care Coordinator and Sales Director no later than June 28th, 2019 on obtaining a serious cognitive impairment statement from a physician prior to admission to a safe secure unit. 3). An audit of current Memory Care Unity residents will be conducted by the Executive Director to verify a serious cognitive impairment statement has been obtained from the physician prior to admission to the safe secure unit no later than June 28th, 2019. 4). To monitor for ongoing compliance, a monthly audit will be conducted by the Executive Director /designee times three (3) months. Additional audits will be conducted based on audit findings.
Standard #:	22VAC40-73-1110-A
Description:	Based on resident record review, the facility failed to ensure a written determination from the administrator for appropriate placement in a special care unit was completed prior to admission. Evidence: 1. Resident 1's record did not have documentation from the administrator determining placement on a safe secure unit was appropriate prior to admission. Resident 1 was admitted to the safe secure unit on 4/1/19.
Plan of Correction:	1). The Serious Cognitive Assessment Form will be completed for resident #one (1) identified no later than June 18th, 2019. 2). The District Director of Clinical Services/designee will retrain the Executive Director, Health and Wellness Director, Resident Care Coordinators, and the Director of Sales no later than June 18th, 2019, related to 22 VAC 40-73-1110 A requirements. 3). An audit will be conducted of the medical records of current residents on the memory care unit to verify that the Serious Cognitive Impairment forms are in place, no later than June 28th, 2019. 4). To monitor for ongoing compliance, an audit will be conducted weekly for two (2) months by the Health and Wellness Director/designee to verify that the Serious Cognitive Impairment forms have been completed for residents residing on the community memory care unit.
Standard #:	22VAC40-73-100-C-1
Description:	Based on medication cart audit, the facility failed to implement an infection control program following CDC guidelines for blood glucose monitoring. Evidence: 1. Unlabeled glucometers were noted in the bags on the medication cart for residents 11, 12 & 13. 2. Medication cart #2 had 2 out of 4 glucometers labeled.
Plan of Correction:	1). The Glucometers for the residents # eleven (11), twelve (12), and thirteen (13) have been labeled with the names of the residents. The glucometer storage containers have also been labeled accordingly. 2). Re-training by the Health and Wellness Director / Designee will be conducted for RMAs and LPNs regarding glucometer storage and labelling no later than June 28th, 2019. 3). An audit of medication carts has been conducted by the Health and Wellness Director/ Designee to verify that glucometer are labeled with the name of the residents on the glucometer and on the outside of the glucometer storage container. 4). To monitor for ongoing compliance, a monthly audit of medication carts will be conducted by the Health and Wellness Director /Designee for two (2) months to verify glucometers and the storage containers are labeled with the residents names. Results of the audits will be reviewed by the Executive Director, who will determine if additional audits are warranted and will be based on audit findings.
Standard #:	22VAC40-73-120-A
Description:	Based on resident record review and staff interview, the facility failed to ensure orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervision of a trained direct care staff person or administrator. Evidence: 1. Staff 4 was hired on 7/17/18. Staff 4 did not received training an orientation on the following from subsection B & C: a) The purpose of the facility; b) The facility's organizational structure; c) The services provided; d) The daily routines; e) The facility's policies and procedures; f) Specific duties and responsibilities of their positions; g) Required compliance with regulations for assisted living facilities as it relates to their duties and responsibilities. h) Emergency and disaster plans for the facility; i) Procedures for the handling of resident emergencies; j) Use of the first aid kit and knowledge of its location; k) Handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures specified in 22 VAC 40-73-100; l) Confidential treatment of personal information; m) Requirements regarding the rights and responsibilities of residents; n) Requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in ? 63.2-1606 of the Code of Virginia; 8) Procedures for reporting and documenting incidents as required in 22 VAC 40-73-70; o) Methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and p) For direct care staff, the needs, preferences, and routines of the residents for whom they will provide care. Staff 10 & 11 confirmed the facility was not in compliance with this standard.
Plan of Correction:	1). Staff member # four (4) will complete orientation training as outlined in 22VAC 40-73-(3)-120-A. This training was conducted by the Executive Director/Designee audit of staff training records will be conducted by the Executive Director/designee to verify that required training has been completed and documented no later than June 28th, 2019. 3). To monitor for ongoing compliance, a monthly audit of staff training records will be conducted by the Executive Director/Designee for six (6) months to verify completion of required training. Additional audits will be directed by the Executive Director, based on audit findings.
Standard #:	22VAC40-73-310-B
Description:	Based on residents' record review, the facility failed to ensure a documented interview was completed prior to all residents admission. Evidence: 1. Resident 1, admitted on 4/1/19, and resident 5, admitted on 4/25/19, did not contain any documentation indicating a preadmission interview was conducted.
Plan of Correction:	1). Unable to retroactively correct the missing documented conversations at the time of admission for resident #one (1) and five (5) identified. Updated documented conversations will be conducted by the Executive Director no later than June 19th, 2019. 2). The District Director of Operations/designee will retrain the Executive Director regarding 22VAC 40-73- 310B no later than June 28thth, 2019. 3).To monitor for ongoing compliance, weekly audit will be conducted by the Executive Director /Designee for two (2) months to verify completion of documented conversations before or at the time of admission. The ED will be responsible for directing additional action, based on audit findings.
Standard #:	22VAC40-73-390-A
Description:	Based on residents' record review, the facility failed to update resident agreements when changes in policies and other information occurred. Evidence: 1. Residents 6 & 9's records contained outdated agreements, which did not include all information required by the February 2018 regulation changes. 2. Resident 1 was admitted on 4/1/19. On 5/28/19, the agreement addendum was signed.
Plan of Correction:	1).Unable to retroactively correct the date of signing of the Residency Agreement Addendum for the residents # six (6) and nine (9). 2). The Residency Agreement has been updated to meet 22VAC 40 -73- 390 A and will continue to be completed for new admissions. Current residents or the resident?s legal representative will complete the Residency Agreement Addendum no later than June 28th, 2019. 3). An audit will be conducted by the Executive Director/ designee to verify that current residents or their legal representative has completed the Residency Agreement Addendum no later than June 28th, 2019. 4).To monitor for ongoing compliance, monthly audits of Residency Agreements will be completed by the Executive Director for three (3) months. Additional corrective action will be directed by the ED based on audit findings.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record reviews, the facility failed to ensure uniform assessment instruments (UAIs) were completed as required. Evidence: 1. Resident 3's 11/28/18 UAI assessed mechanical & human help with bathing and mechanical help & supervision with mobility. The individualized service plan (ISP), dated 11/28/18, indicates mechanical help with bathing and mobility. Staff 5 confirmed the UAI is incorrect and the ISP is correct. 2. Resident 5's 4/25/19 UAI is not signed and approved by the Administrator. 3. Resident 7's 8/7/18 UAI assessed no help with dressing and did not assess transferring. The 8/7/18 ISP dated denotes mechanical help with dressing and transferring. Staff 5 confirmed the UAI is incorrect and the ISP is correct.
Plan of Correction:	1). The Uniform Assessment Instrument and Individual Service Plan for resident #three (3) has been reviewed by the Health and Wellness Director (HWD) and corrected to reflect accurate care needs for bathing and mobility. For resident # five (5), a signature has been obtained on the Uniform Assessment Instrument. For resident #seven (7) the Uniform Assessment Instrument has been corrected by the Health and Wellness Director (HWD) to reflect accurate care needs for dressing and transferring. 2). Staff certified to complete the Uniform Assessment Instrument and Individualized Service Plans will be re-trained by the District Director of Clinical Services / Designee no later than June 28th, 2019. 3). An audit will be completed by the Executive Director /Health and Wellness Director for Uniform Assessment Instruments and Individual Service Plans of current residents for accuracy for (2) two months. 4). To monitor for ongoing compliance, audits will be completed by the Executive Director/ Health and Wellness Director for three (3) months to verify compliance goals are met. Additional actions will be based on audit findings.
Standard #:	22VAC40-73-450-C
Description:	Based on residents' record review, the facility failed to ensure all identified needs were addressed on individualized service plans (ISPs). Evidence: 1. Resident 1's 4/1/19 physical denotes an allergy to Sulfa. The 3/29/19 ISP denotes an allergy to Penicillin. 2. Resident 4's 8/15/18 UAI assessed mechanical and human help with dressing, toileting, transferring and wheeling. The 8/15/18 ISP denotes physical assistance with these activities. Staff 5 confirmed the ISP is incorrect and the UAI is correct. Furthermore, resident 4 has a signed Do Not Resuscitate (DNR) order, dated 10/25/18 and a signed physician's order dated 5/1/19 to change the resident oxygen to 2 liters/min. The ISP does not address these newly identified needs.
Plan of Correction:	1). Resident #one (1) Individual Service Plan has been updated to reflect an allergy to Sulfa. Resident # four (4) Individual Service Plan has been updated to reflect the accurate care needs for dressing, toileting, transferring and wheeling. 2). The District Director of Clinical Services/Designee will retrain the staff members certified to complete Individual Service Plans by June 28th, 2019. 3). An audit for accuracy of current Individual Service Plan will be conducted by the Health and Wellness Director/designee no later than June 28th, 2019. 4). To monitor for ongoing compliance, a monthly audit will be conducted by the Health and Wellness Director / designee times three (3) months. Additional audits will be 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. Resident 8's 3/28/19 ISP denotes hospice services are received but does not include a description of these services.
Plan of Correction:	1). The Individualized Service Plan for resident #eight(8) will be updated by the Executive Director/ Designee to reflect the detailed coordinated plan of care on the Individualized Service Plan for Hospice no later than June 18th, 2019. 2). An audit will be conducted by the Executive Director/ Designee for current hospice residents to verify a detailed coordinated plan of care is documented, no later than June 28th, 2019. 3).To monitor for ongoing compliance, monthly audits of the hospice resident?s coordinated plan of care will be completed by the Executive Director/Designee for three (3) months. Additional corrective action will be at the direction of the ED, based on audit findings.
Standard #:	22VAC40-73-640-A
Description:	Based on observations and document review, the facility failed to successfully implement their medication management plan. Evidence: 1. Resident 11's Novolog insulin had an open date of 4/15/19. Manufacturer instructions are to discard this medication 28 days after opening. The facility's medication management plan requires all expired medications to be disposed of, not remain the medication cart. 2. Resident 18's Alprazolam tablet #20 in the pack had tape over it. The bubble pack was punctured and tape was placed over contaminated medication. Staff 9 confirmed the facility was not in compliance with this standard. 3. Resident 19's Novolin R expired on 5/26/19. The open date was 4/14/19. The FDA's website only allows for 28 days after opening before it is expired. 4. The controlled substance/MAR shift change of audit form for May 2019 is missing staff signatures and/or count information on the 1st, 2nd, 7th, 11th, 12th, 13th, 14,th, 15th, 16th, 17th, 21st, 22nd, 23rd, 24th, 27th, 28th & 29th. The facility medication management plan has documentation that controlled substance will be counted by the off going shift and the oncoming shift employees and the signatures of both staff will be documented on the controlled substance count sheet. Staff 9 confirmed the form was not complete on medication cart #2 because there was no form in the book.
Plan of Correction:	1).The expired Novolog Insulin for resident #eleven (11) that had not been administered before the 28 day expiration date has been discarded and replaced. The community is unable to retroactively correct omissions on the narcotic record. We are unable to retroactively correct the missing staff signatures for the narcotic sheet for cart #two (2). The card of Alprazolam for resident # eighteen (18) has been destroyed as outlined by the community?s Medication Destruction Policy and was replaced by the community prior to 5/30/19, in time for the next dosing as ordered by the Physician. The expired Novolin Insulin for resident # nineteen (19) has been discarded and replaced by the community for the next Physician ordered dosing. 2). Re-training of RMAs and LPNs will be conducted by the Health and Wellness Director/Designee related to expiration of medications, narcotic destruction and the Narcotic Count policy no later than June 28th, 2019. 3). To assist with ongoing compliance, audits will be conducted by the Health and Wellness Director/ Designee weekly for two (2) months to verify narcotic records are in place without omissions, expired medications have been removed from the cart, discarded per community policy, and verifying there is no tape on the back of medication bubble packs.
Standard #:	22VAC40-73-680-B
Description:	Based on a medication cart audit, the facility failed to maintain all medications in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. Voltaren Gel 1% was loose in medication cart #2. It was not in the pharmacy issued container, did not have a prescription label nor a resident's name. Staff 9 was unsure whose medication it was. 2. No less than 25 clear nicotine transdermal system medications were loose in the cart. Staff 9 confirmed the facility was not in compliance with this standard.
Plan of Correction:	1). A pharmacy issued container and label were supplied for the identified Voltaren Gel by May 30th, 2019. 2). The District Director of Clinical Services will retrain the Health and Wellness Director and Resident Care coordinator regarding labeling requirements for medications no later than June 28th, 2019. 3). The Health and Wellness Director/Designee retrain the licensed and certified nursing staff no later than June 28th, 2019. An audit will be conducted by the Health and Wellness Director/Designee of medication carts to verify current medications have appropriate pharmacy label and container no later than June 28th, 2019. 4). To monitor for ongoing compliance, a weekly audit will be conducted by the Health and Wellness Director/Designee for two (2) months, to verify medications have the pharmacy issued labels and containers. Audit findings will be reported to the Executive Director, who will direct additional action based on audit findings.
Standard #:	22VAC40-73-980-A
Description:	Based on physical plant observation and staff interview, the facility failed to have a complete first aid kit on hand. Items with expiration dates must not have dates that have already passed. Evidence: 1. Staff 10 confirmed the memory care nursing station first aid kit had antispetic wipes/ointment which expired in September 2018.
Plan of Correction:	1). The antiseptic wipes for the first aid kits on the memory care unit nursing station were replaced on June 1st, 2019. 2). The District Director of Clinical Services will retrain the Health and Wellness Director and Resident Care Coordinator on First Aid kit maintenance. 3). The Health and Wellness Director/Designee will retrain RMAs and licensed nursing staff on First Aid kit maintenance no later than June 28th, 2019. 4). To monitor for ongoing compliance, an audit will be completed monthly for two (2) months by the Health and Wellness Director/Designee to verify the First Aid supplies have not expired in the First Aid kit. Audit findings will be reported to the Executive Director, who will direct additional action, based on audit findings.
Standard #:	22VAC40-73-980-B
Description:	Based on physical plant observation and staff interview, the facility failed to have a complete first aid kit on hand in the transport vehicle. Items with expiration dates must not have dates that have already passed. Evidence: 1. Staff 7 confirmed the van first aid kit had Dr. Shefield's triple antibiotic ointment which expired in October 2016.
Plan of Correction:	1). The First Aid kit for the community vehicle has been replaced as of June 1st, 2019. 2). The District Director of Clinical Services will retrain the Health and Wellness Director and Resident Care Coordinator on first aid kit maintenance. 3). The Health and Wellness Director/Designee will retrain RMAs and licensed nursing staff on First Aid kit maintenance no later than June 28th, 2019. 4). To monitor for ongoing compliance, an audit will be completed monthly for two (2) months by the Health and Wellness Director/Designee to verify the first aid supplies have not expired in the first aid kit. Audit findings will be reported to the Executive Director, who will direct additional action based on audit findings.
Standard #:	22VAC40-73-990-C
Description:	Based on staff interview, the facility failed to ensure at least every six months all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. Staff 7 & 10 were unable to provide documentation to demonstrate compliance with this standard. The last documentation was dated 8/28/18.
Plan of Correction:	1). Unable to retroactively correct missing training on Resident Emergencies and Practice Exercises, however this training will be conducted by the Executive Director/Designee no later than June 18th , 2019, and ongoing every six (6) months. This training will include the six scenarios. 2). To monitor for ongoing compliance, an audit will be conducted by the Executive Director/designee every six (6) months for two (2) years to verify that staff have participated in the exercises and have documentation of practice exercises on resident emergencies.
Standard #:	22VAC40-90-40-H
Description:	Based on private duty personnel record review, the facility failed to ensure anyone convicted of a barrier crime is not working within the facility. Evidence: 1. Private duty personnel 1's record contained a criminal background check with a 10/31/2000 felony conviction. The felony conviction violates Code of Virginia barrier crime 18.2-51.
Plan of Correction:	1). Unable to retroactively correct the Private Duty Agency Provider from ?Nexus? with a felony conviction .The Private Duty employee was discharged from the community on May 30th, 2019. 2). The District Director of Clinical Services will retrain the Executive Director, Business Office Manager, and Health and Wellness Director regarding Sworn Disclosure for third party providers and verification of background checks prior to initiation of services, no later than June 28th, 2019. 3). To monitor for ongoing compliance, a monthly audit of current third party vendors providing services in the community will be conducted by the Executive Director/Designee for two (2) months to verify signed sworn disclosure and background checks are present. Additional audits will be directed by the Executive Director, based on audit findings.