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: March 30, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The licensing inspector, accompanied by two other LIs, conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 03/02/2020. The LI reviewed documentation, toured the facility, and conducted interviews relating to allegations of inadequate supervision. The information gathered during the investigation does not support the allegation, so the complaint is determined to be ?not valid.? There are no violations resulting from this complaint; however, other violations did result from this complaint investigation. Please sign, date, and return this notice to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	930-D Based on record review, the facility failed to ensure that resident rounds were documented and retained. EVIDENCE: Resident 1 was admitted to the facility?s special care unit in October 2019 and had been assessed as having a high fall risk rating. After interviewing staff 1, the facility was unable to locate documentation that regular rounds had been made in an effort to prevent falls during the length the resident?s stay.
Plan of Correction:	22VAC40-73-(8)-930-(D) Corrective Action 1). Unable to locate or retroactively correct documentation for the dates identified during the complaint inspection. Rounds continue to be regularly completed as required and documentation is maintained. How to Identify Others 1). The Health and Wellness Director or designee will audit resident rounds records to ensure that they are present in their prescribed location. Systemic Changes 1). Re-training of Nursing and Direct Care staff by the Health and Wellness Director, to include proper maintenance of regular round documentation as required. no later than 03/31/2020 Monitoring 1). The Health and Wellness Director / Designee will conduct a weekly audit times four (4) weeks to verify that rounds documentation is completed and maintained.