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: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The Division of Licensing Programs received an anonymous complaint in regards to Brookdale Harrisonburg. The complaint alleges that the facility is covering up medication/insulin errors, not providing wound care needs, falsifying documentation, not reporting incidents and has residents with exit seeking behaviors on the AL side that are not being addressed. A complaint investigation 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 Home Office consultant. Resident and staff records as well as other forms of facility documentation including incident reports were reviewed. A tour of the facility physical plant was conducted and the morning medication pass was observed. The facility medication carts were audited and medication administration records were observed. Interviews were conducted with residents and staff. The LI noted that the facility does have a mixed population that includes residents with cognitive impairments on the AL side of the building. The facility front door was noted to be unlocked on the day of inspection, unattended and did not contain a system of security monitoring for residents with serious cognitive impairments. Based on all information made available for review this part of the complaint is valid. Please respond back to this violation notice with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact the facility Licensing Inspector.

Violations:

Standard #:	22VAC40-73-1040-A
Complaint related:	Yes
Description:	Based on a review of resident records and observations of the facility physical plant, the facility failed to have a a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms on all doors leading to the outside. EVIDENCE: 1. The record for resident 7, who resides on the AL side of the facility, has documentation on the history and physical dated 7/30/18 that the resident has a diagnosis of dementia with cognitive impairments. The uniform assessment instrument (UAI) dated 3/4/19 for resident 7 has that the resident is disoriented to some spheres some of the time with periods of confusion to place and time and needs redirection at times. The UAI also has resident 7's behavior pattern as wandering weekly or more. It was observed that the front door to the AL part of the building was unlocked throughout the day of inspection, unattended and did not have a system of security monitoring for residents with cognitive impairments. An interview with staff person 1 expressed that the door is only secured between the hours of 8pm to 8am each night.
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 15th, 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. 1). Resident #7 MD has been re-evaluated by the Health and Wellness Director/Nurse designee. Resident #7?s legal representative has reviewed the re-evaluation and has agreed with Memory Care placement. Resident #7 is currently residing on the secured Memory Care unit. 1) An audit of residents who have a primary diagnosis of dementia has been completed by the appropriately trained nurses. UAI?s have been reviewed, by the appropriately trained nurses, for current residents of the Assisted Living. A Montreal Cognitive Assessment (MoCA) will be completed by the Executive Director (ED) and/or appropriately trained designee, as part of the re-evaluation process and to assist with a determination of ongoing residence on the Assisted Living, no later than August 1, 2019. 1). Prior to admission , readmission , with noted changes in baseline of cognition, as well as new residents with a primary diagnosis of dementia, the Executive Director/ designee will evaluate appropriateness of admission or continued placement of assisted living residents by completing the MoCA and will alert the District Director of Clinical Services for review. 1). Residents with a primary diagnosis of dementia or noted to have changes in cognition will be reviewed using the MoCA test. The primary MD will be notified of findings, along with the District Director of Clinical Services. If it is determined that the resident has cognitive impairment, based on the MoCA assessment, then this may be indicative of the need for Memory Care placement. A care plan meeting will be held with the resident and their legal representative. Residents will be reviewed in the Collaborative Care Meetings twice monthly for changes of condition. To assist with compliance, these reviews will be conducted by the Executive Director / Health and Wellness Director / Designee.