VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Danville Piedmont
149 Executive Court
Danville, VA 24541
(434) 799-1930

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Nov. 7, 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

Technical Assistance:

1070 B. The facility is licensed to provide care for a mixed population. Currently no residents are in care that have a serious cognitive impairment and exhibit any indication that normal objects could be choking hazards. Numerous small game pieces, small puzzle pieces, un-popped corn and small round glass pebbles were observed in a kitchenette/sitting area. These items are used for crafts and or activities. If the population changes, these items could present choking hazards and would need to be secured. 640 A. The facility does have a method to count controlled substances but if there are problems with the count there is no way to be specific about what mediation there is a problem with. It is suggested that staff be trained on who to contact if there are discrepancies in the count. 650 E. Physician's orders are required to be maintained in chronological order in resident files. Most physician's orders were chronologically arranged but a few were not, making it difficult to find physician's orders.

Comments:

Three licensing inspectors conducted an unannounced license renewal inspection at Brookdale Danville on 11/07/2019. The inspection began at 8:15 am and concluded at 2:57 pm. A tour of the building and grounds was conducted. Residents and collaterals were interviewed. Resident and staff interactions were observed. Breakfast and lunch were observed and the noon medication pass was observed. A sample of resident and staff files were reviewed. Medications and Medication Administration Records were observed. The facility was found to have 56 residents in care at the time of the inspection. Required postings and the previous inspection were observed to be in place. An exit meeting was conducted with the administrator and other key staff on 11/07/2019 and at that time the opportunity was given to find items that were not readily available in the records. As a result of this inspection, 13 violations are being cited. A corrective action plan should be developed addressing the steps to correct the noncompliance of teach standard; measures to prevent the reoccurence; and person(s) responsible for implementing each step and/or monitoring and prevention measures. The description of action to be taken for each violation along with the date to be corrected must be returned to the licensing office signed and dated within 10 calendar days (11/25/2019) if receipt. If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-290-B
Description:	Based on observations and staff interviews, the facility failed to implement their procedure for posting the name of the current on-site person in charge. EVIDENCE: 1. Upon arrival to the facility at 8:15 am on November 7, 2019, a dry erase board was observed sitting on a table in the foyer. The dry erase board included information regarding the staff person in charge however it was dated November 5, 2019. 2. Staff # 1 and Staff # 2 expressed verbal confusion over which one of them was in charge, since the administrator had not arrived for the day.
Plan of Correction:	A sign was immediately posted with the name and date of the person in charge. Associates responsible for updating posting of on-site person in charge have been reeducated by the Executive Director/Designee. Associates will be trained by the Health and Wellness Director/Designee on how to read the schedule to determine on-site person in charge. This training will be provided no later than November 30, 2019. ED/HWD/Designee will review posting of on-site person in charge weekly for four (4) weeks and montly for two months, then at unannounced intervals as needed to monitor for ongoing compliance. [sic]
Standard #:	22VAC40-73-560-F
Description:	Based on observations made during the morning tour of the building, the facility failed to maintain all resident records in a confidential manner. EVIDENCE: 1. Around 8:30 am a manila envelope was observed in a wall holder labeled "Dr. Appts." This wall holder was located between the laundry room and a storage room. 2. Confidential medical and personal information including insurance numbers, social security number, birth date and medical history for Resident # 14 were in this unsealed envelope. 3. the Mt. Cross Narcotic count book was observed on the top of the medication cart unattended. The Narcotic Count book contains resident specific information regarding prescription of narcotics and how many pills are left for each resident on the medication cart.
Plan of Correction:	The wall holder labeled "Dr. Appointments" was removed and placed in the locked medication room. The location for the Narcotic books has been changed and will be kept in the bottom locked drawer of medication cart effective immediately. Associates will be in-services by the Health and Wellness Director/Designee on confidentiality of resident records and where doctors' appointment envelopes and narcotic books will be kept to maintain confidentiality. This training will be completed by November 30, 2019. HWD/Designee will monitor placement of confidential information weekly for (4) weeks and monthly x 2 months. [sic]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the morning tour of the building and interviews with the staff, the facility failed to place any menu substitutions or additions on the posted menu. EVIDENCE: 1. The Licensing Inspector observed the posted menu for the week and on the day of inspection pancakes were to be served for breakfast. While observing breakfast bacon, eggs, and toast were being served. The kitchen staff stated that pancakes were not being served on the day of the inspection. A substitution for bacon, eggs, and toast were not recorded on the posted menu.
Plan of Correction:	Associates responsible for menu planning will be trained by the Executive Director/Designee on meal substitutions and updating menu when changes are made. Executive Director/Designee will audit menu postings for accuracy weekly for (4) weeks. The Executive Director/Designee will audit the menu, meal substitutions and updating of the menu ongoing thereafter. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit for the Tbird cart, the facility failed to ensure the implementation of their medication management plan. EVIDENCE: 1. Resident # 2 was prescribed Metoprolol Tartrate 25 mg tablets to be taken twice daily for hypertension. This medication was discontinued by a physician's order dated 11/01/2019; the medication was still on the medication cart.
Plan of Correction:	Resident # 2: discontinued medication has been removed from the medication cart. Training will be conducted by the Health and Wellness Director to the registered and licensed nursing staff regarding the Discontinued Medications Policy no later than December 1st, 2019. HWD/Designee will audit medication carts weekly for four (4) weeks for discontinued medications and to verify removal. Associates will be trained on the medication management plan for the removal of discontinued medications at the time of physician order. HWD/Designee will audit medication carts weekly for four (4) weeks and monthly ongoing.
Standard #:	22VAC40-73-650-A
Description:	Based on documentation review and staff interviews, the facility failed to obtain physician's orders prior to stopping, starting or changing a medication for all residents in care. EVIDENCE: 1. Resident # 7's Medication Administration Record (MAR) shows that she is receiving Torsemide 20 mg 1 tablet every day. The MAR shows that this medication was started on 09/05/2019. there was no order dated 09/05/2019 for Torsemide. An order dated 09/27/2019 stated Torsemide 20 mg one tablet twice daily until Monday and an order dated 10/03/2019 sated Torsemide 20 mg one tablet daily. There was no clarification for the orders for the Toresmide. 2. Resident # 7 has a physician's order for Levothyroxine 75 mcg one every day ordered on 08/05/2019 and an order for Synthroid 88 mcg 1 hour before breakfast ordered 10/10/2019. Resident # 7 is receiving Synthroid 88 mcg every day but there was no discontinue or change order for the Levothyroxine 75 mcg. Levothyroxine is generic for Synthroid. 3. Resident # 7 has a physician's order for Tramadol 50 mg 1/2 tablet at 8:00 am.; noon; and 8:00 pm dated 08/05/2019. She also has an order for and is receiving Tramadol 50 mg three times daily ordered 09/20/2019. There was no discontinue or change order for the Tramadol 50 mg 1/2 tablet that was ordered on 08/05/2019. 4. One medication order does not supersede another in Assisted Living regulations. 5. Resident # 7 has a physician's order dated 12/11/2018 for Celebrex 200 mg one every day; Cozaar 100 mg one every day and Lasix 40 mg on twice daily. These medications were not on the resident's MAR and were not available for administration but there was no discontinue order available for these medications. 6. According to the MAR for Resident # 12 she was prescribed Vitamin C gummies 250 (ascorbic acid) that had been changed to Ascorbic Acid 250 mg tablets. A physician's order for this change could not be located.
Plan of Correction:	Medications for resident #7 and #12 have been clarified to follow Physician's orders. Associates responsible for medication administration will be trained by HWD/Designee on how to obtain physician orders prior to stopping, starting, or changing a medication no later than December 31, 2019. HWD/Designee will audit orders weekly for four (4) weeks to verify orders are written per Physicians and available on the medication cart for administration. The Health and Wellness Director/Designee will conduct monthly audits for two months at unannounced intervals thereafter. [sic]
Standard #:	22VAC40-73-660-A-6
Description:	Based on observations made during the tour of the building, the facility failed to maintain all dietary supplements in a locked area. EVIDENCE: 1. Five bottles of Ensure with no resident name on them were observed in the unlocked refrigeration in the resident dining room.
Plan of Correction:	Dietary supplements have been removed from unlocked refrigeration in the resident dining room and moved to locked medication room. Training will be conducted by the Health and Wellness Director/Designee regarding the requirement for resident's supplements to be maintained in a locked refrigerator and labeled appropriately. Executive Director/Health and Wellness Director/Designee will audit dietary supplement storage weekly for four (4) weeks and monthly thereafter. [sic]
Standard #:	22VAC40-73-660-B
Description:	Based on observations made during the noon medication pass, the facility failed to maintain all medications in a locked area for all residents rated dependent in medication administration. EVIDENCE: 1. Resident #2 was admitted to the facility on 10/11/2019. His Uniform Assessment Instrument (UAI) dated 10/25/2019 states that he requires the assistance of a nurse/lay person to administer his medications. His physical examination form dated 10/08/2019 states that medications are to be administered by facility staff only. 2. During the noon medication pass the licensing inspector observed Triple Antibiotic Ointment in an open bedside table drawer and medicated cough drops on top of the bedside table. 3. There were no physician's orders available for Resident #2 to self-administer these medications.
Plan of Correction:	Resident # 2: Resident medications were removed from the bedside immediately and the resident was informed of the Medication Administration policy by the Licensed Nurse. The Health and Wellness Director (HWD) or Designee has contacted the physician for clarification orders regarding medications the resident chooses to keep at bedside. The Resident will be required to pass a medication Self-Administration evaluation in order to allow this. This includes the requirement that a resident is able to properly secure the medication and keep their apartment locked when not inside. Executive Director/Designee will complete room audits weekly for six (6) weeks to check for residents with meds at bedside. In the event medications are found at the bedside a nurse will evaluate the resident using the Medication Self-Administration Evaluation form, and orders for self-administration of medications will be requested where appropriate. Residents who chose to self-administer medications will be informed by the Executive Director (ED) of the Medication Self-Administration Policy, the need for a physician order for the medication (including over the counter medications) and the requirement to keep all medications properly secured. Training will be conducted by the Health and Wellness Director/Designee to registered, licensed and direct care associates on self-administration orders and the securing of medications for residents with self-administration orders. Executive Director/Designee will do room audits weekly to monitor for medications at bedside for four (4) weeks then monthly for two months. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the medication cart audits, the facility failed to administer all medications in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident # 7 has a physician's order for and received Azelastine Nasal Spray. this opened bottle was not labeled with an opened date.
Plan of Correction:	Resident #7: nasal spray has been removed from cart by the licensed nurse and a new bottle was ordered and labeled with date opened. The Health and Wellness Director/Designee will train registered and licensed associates who are responsible for medication administration in regards to dating bottles when opened. Health and Wellness Director/Designee will audit medication carts weekly for four (4) weeks and monthly thereafter to verify date opened labels are present on nasal sprays. [sic]
Standard #:	22VAC40-73-680-E
Description:	Based on documentation review, the facility failed to document the performance of all medical treatment for residents in care. EVIDENCE: 1. Resident # 10 has a physician's order dated 07/05/2019 for TED hose during waking hours. 2. There was no documentation that the TED hose were being worn during waking hours.
Plan of Correction:	Resident #10: Now has documentation on the MAR to indicate that ted hose are being worn. This has been added to the Physician Order Sheet. Health and Wellness Director/Designee will train registered and licensed associates responsible for medication administration on ted hose being worn according to physicians order and the need to add an order on the Physician Order Sheet and place on the MAR. Heath and Wellness Director/Designee will audit medication administration records weekly for four (4) weeks and monthly.
Standard #:	22VAC40-73-680-I
Description:	Based on documentation review, the facility failed to maintain all required information on all resident Medication Administration Records (MARs). EVIDENCE: 1. Resident # 10 has a physician's order for Tramadol 50 mg take 0.5 tablet every 8 hours as needed. The MAR shows that Tramadol was given on 11/02/2019 but the exact dose, symptoms for which the medication was given and effectiveness was not documented. 2. Resident # 2 has a physician's order for Tramadol 50 mg take one every 6 hours as needed. The MAR shows that this medication has been given three times in November but the exact dose, symptoms for which the medication was given and effectiveness was not documented.
Plan of Correction:	The order for resident #10's Tramadol will be clarified and entered with the appropriate dose and symptoms for which the Tramadol is being administered no later than November 25th, 2019. Licensed and registered associates responsible for medication administration will be trained b Health and Wellness Director/Designee regarding as need (PRN) documentation for dose, symptoms, and effectiveness no later then December 31st, 2019. An audit will be conducted to clarify other residents affected. The Health and Wellness/Designee will review as needed medications weekly for four (4) weeks and monthly thereafter. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the medication cart audits, the facility failed to maintain all as needed medications available to residents. EVIDENCE: 1. Resident # 7 has a physician's order for Meclizine HCL 25 mg one tablet every 24 hours as needed for dizziness. This medication was not available in the facility. 2. Resident # 13 is prescribed Benadryl Tablets give 25 mg by mouth every 6 hours as needed for itching and Imodium A-D 2 mg capsules give a capsule by mouth every 6 hours as needed for chronic diarrhea. Neither medication was available on the medication cart for administration. 3. Resident # 12 is prescribed 10 mg Dulcolax Suppository's every 24 hour as needed for constipation, fleet oil enema every 24 hours as needed for constipation, and Milk of Magnesia Suspension 400mg/5ml give 30 ml by mouth every 24 hours as needed for constipation. None of these medications were available on the medication cart for administration. 4. Resident # 11 is prescribed 100 mg Colace capsules give 1 capsule every 12 hours as needed for constipation. This medication was not available on the medication cart for medication administration.
Plan of Correction:	Resident #7, #11, #12, and # 13: as needed medications were ordered from pharmacy by the nurse, are now available as per physician order. HWD/Designee will audit carts weekly for four (4) weeks for prn medication availability and randomly thereafter. Training by the health and Wellness Director/Designee will be conducted no later than December 1st, 2019 to registered and licensed associates regarding actions to take in the even prn meds are unavailable. Executive Director/Designee will conduct prn (as needed) medication availability audits weekly for four (4) weeks and monthly for 2 months. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the morning tour of the building, the facility failed to maintain all areas in a clean manner. EVIDENCE: 1. The inside of the cabinet in the resident dining room under the coffee and juice dispenser was observed to be black with stains and caked on dirt. The front of these same cabinet drawers had coffee and juice stains running down the length of the cabinet. The inside of the drawers in this cabinet were black/brown with dirt and coffee drips and stains. 2. The front of the cabinet doors and drawers where the microwave was sitting in the resident dining room were observed to be dirty and stained. 3. The kick/toe area under both cabinets were black with dirt and stains.
Plan of Correction:	The cabinet in the resident dining room will be replaced/repaired by January 15, 2020. Associates will be trained by the Executive Director/Designee no later than November 30, 2019 on a schedule for monitoring and cleaning the cabinets in resident dining room. Executive Director/Designee will audit cabinets for cleanliness weekly for four (4) weeks and monthly x 2 months. [sic]
Standard #:	22VAC40-73-930-B
Description:	Based on resident and staff interviews and call bell trial, the facility failed to maintain an operable signaling device for all residents in care. EVIDENCE: 1. During an interview with Resident #15 she reported that she had fallen the evening before and the call bell (a pendant device) did not work. 2. The licensing inspector tried using the pendant device to call for assistance and no staff responded. 3. During interviews with three staff members it was determined that the pendant was not operational.
Plan of Correction:	Resident #15: call belll signaling device has been repaired. Executive Director/Designee will complete audits of call bell signaling devices weekly for four (4) weeks to verify call signaling devices are in working order for all apartments. Training will be provided by the Executive Director/Designee to the Maintenance Director and associates in regards to checking call signaling devices for proper working order and the need to immediately report concerns to the Executive Director/Designee. The Executive Director/Designee will audit call signaling devices for working order monthly for two months. [sic]