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: Nov. 19, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 11/19/2019 one inspector conducted a complaint investigation (1:25PM to 3:40PM) involving an allegation that a resident was not being bathed frequently enough. Staff was interviewed and shower logs were reviewed. Based on available evidence, 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 #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on document review, the facility failed to ensure that a resident was bathed at least twice a week. EVIDENCE: 1. The facility shower logs show that resident 1 is not being bathed at least twice a week, and there is a period in September 2019 that shows he went two weeks between bathing. The shower logs for resident 1 document showers on: August 8, 15, 16, and 26, 2019; September 2, 16, 19, 26, 29, and 30, 2019; October 3, 7, 10, 17, 21, and 28, 2019; and November 4, 7, 11, and 14, 2019.
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 Inspection which took place on November 19th,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 showers or baths not previously provided during identified time frame. How to Identify Others 1). The Health and Wellness Director or designee will audit resident records for compliance with assigned showers or baths to verify that residents are receiving two (2) showers or baths on a weekly basis utilizing the caregiver assignments. Systemic Changes 1). Re-training of Direct Care Associates to be conducted by the Health and Wellness Director or designee, to include new hires, on providing two (2) showers or baths weekly for residents as outlined in the Individual Service Plan Refusals. Resident refusals to showers or baths will be reported to the Wellness Nurse or designee for documentation. Monitoring 1). The Health and Wellness Director / designee will audit 25% of caregiver assignments weekly for compliance with resident showers or baths per ISP.