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: Aug. 6, 2019 and Nov. 19, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 8/6/2019 one inspector began a complaint investigation (6:50PM to 7:25PM) regarding food at the facility. The inspection concluded 11/19/2019 (1:25PM to 4:05PM). Evidence gathered during the investigation shows the complaint is valid. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. 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). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-610-D
Complaint related:	Yes
Description:	Based on interview and document review, the facility failed to serve prescribed diets to residents. EVIDENCE: 1. Staff interviews reveal that in August 2019 (exact date unknown), there was no dietary staff to prepare supper for the residents, so on one day they were served pizza from a pizza takeout place, and on another day, the residents were served sandwiches from Firehouse Subs. The Diet Type Report shows that 19 residents at the facility are on special, prescribed diets, and staff was unable to describe to the LI how the prescribed diets were satisfied with pizza or sandwiches from Subway. Resident: Prescribed Diet: 1, liberalized renal; 2, carbohydrate controlled; 3, texture modified; 4, carbohydrate controlled; 5, texture modified; 6, 2gm sodium; 7, texture modified; 8, finger food; 9, carbohydrate controlled; 10, NAS (no added salt); 11, pureed; 12, carbohydrate controlled; 13, carbohydrate controlled; 14, 2 gm sodium; 15, carbohydrate controlled; 16, carbohydrate controlled; 17, texture modified; 18, carbohydrate controlled; 19, NAS (no added salt).
Plan of Correction:	The following is a summary of the Plan of Correction for Brookdale Salem. This Plan of Correction is in regards to a complaint visit on November 19, 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. Corrective Action 1). Unable to retroactively correct prescribed diets not served for the 19 residents on the dates identified during the complaint inspection. Residents will receive the prescribed diets as ordered by the Physician ongoing. How to Identify Others 1). The Executive Director/Designee has verified consistent staffing in the dietary department in order to prepare, plate and serve the prescribed diets as ordered by the Physician. Systemic Changes 1). Re-training of Dining Services Coordinator, dietary associates, and care staff by the Executive Director / Designee to ensure prescribed diets are served accurately and consistently per Physician orders. Monitoring 1). The Executive Director / Designee will conduct monitoring of meals weekly times four (4 ) weeks with additional observations at unspecified times to verify prescribed diets are being served.