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 2, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS

Comments:

The LI for Brookdale Salem, along with two other LIs, conducted an unannounced renewal study on 3/2/2020 from 8:50 am until 5:30 pm, finding 74 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and craft activity. Fourteen resident records were thoroughly reviewed, and an additional nine were partially reviewed in relation to the observation of the medication pass and/or special diets. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of 14 staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. 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: 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, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on staff record review, the facility failed to ensure that new staff had complete new staff orientation. This is required within the first seven working days of employment. EVIDENCE: 1. The RECORD OF INITIAL ALF STAFF TRAINING form shows that staff 3, hired 1/13/2020, completed only one of 17 required areas of training for new staff. 2. The record for staff 4 had no documentation to support that initial staff training has been done. 3. The RECORD OF INITIAL ALF STAFF TRAINING form shows that staff 5, hired 1/21/2020, completed only two of 17 required areas of training for new staff. 4. Staff 1 was hired 12/2/2019, and completed new staff training on 2/27/2020.
Plan of Correction:	? Unable to retroactively correct record of initial staff training for staff 3, staff 4, staff 5 and staff 1. ? The Executive Director, Business Office Manager or Designee will provide Initial staff training for staff 3, staff 4, and staff 5 no later than 5/22/2020. Staff 1 completed initial training on 2/27/20. ? The Executive Director or designee, will provide education for Business Office Manager on Record of Initial staff training and Virginia regulations to be completed by 5/29/2020. ? The Business Office Manager or Designee will audit of all current staff record of initial training for completion of new hire training to be completed by June 30, 2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all current and new staff record of initial training for compliance with new hire training once a month for three months.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to ensure that verification of a staff person receiving a copy of his or her current job description. EVIDENCE: 1. The record for staff 6 lacked verification that this person received a copy of his or her current job description.
Plan of Correction:	? The Executive Director, Business Office Manager or Designee will provide current signed job description for staff 6 no later than 5/22/2020. ? The Executive Director or designee will provide education for Business Office Manager on staff record, job descriptions and Virginia regulations to be completed by 5/29/2020. ? The Business Office Manager or Designee will audit of all current staff records for current signed job descriptions to be completed by June 30, 2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all current and new staff record for signed job description and compliance once a month for three months.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to obtain a TB screening on a new staff person. EVIDENCE: 1. Staff 1 was hired on 12/2/2019 and the file for staff 1 lacks documentation to show that a TB screening was done.
Plan of Correction:	? Unable to retroactively correct receipt of initial tuberculosis screening within 7 days of hire for staff 1 with hire date of 12/2/2019. ? The Executive Director, Business Office Manager or Designee will complete tuberculosis screening for staff 1 no later than 5/29/2020. ? The Executive Director or designee, will provide education for Business Office Manager on staff record, initial and annual tuberculosis screenings and Virginia regulations to be completed by 5/29/2020. ? The Business Office Manager or Designee will audit of all current staff records for initial tuberculosis screening to be completed by June 30, 2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff record for initial tuberculosis screening and compliance once a month for three months.
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review and interview, the facility failed to give staff training in methods of dealing with agitated or aggressive residents prior to being involved in the care of such residents. EVIDENCE: 1. Staff interview confirms that resident 19 is frequently angry or agitated. 2. The file for staff 4 lacks documentation that this training has been done, and staff 4 works in the memory care section. Agitated behavior was observed in memory care on the day of inspection. 3. The file for staff 5 lacks documentation that this training was completed. There is a form, AGGRESSIVE BEHAVIOR TRAINING ALL EMPLOYEES, with staff 5?s name at the top, but no date completed, employee signature, or supervisor signature.
Plan of Correction:	? Executive Director or Designee will provide Direct Care Staff training on Management of Residents with Aggressive Behavior for staff 4 and staff 5 no later than 5/22/2020. ? The Executive Director or designee will provide education for the Health and Wellness Director, Resident Care Coordinator and Business Office Manager on Staff Training for Management of Residents with Aggressive Behaviors by 5/29/2020. ? The Business Office Manager or Designee will audit of all current direct care associate training files for current training on Management of Residents with Aggressive Behaviors and provide training to associates as needed to be completed by June 30, 2020. ? To assist with ongoing compliance, the Executive Director, Business Office Manager or Designee will audit new and current associate training files once a month for three months.
Standard #:	22VAC40-73-350-B
Description:	350-B Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender and document in the resident?s record the results and the date that the results were obtained. EVIDENCE: 1. The record for resident 3, admitted on 01/17/2020, contained no documentation of a sex offender screening and its results. 2. The record for resident 1, admitted on 10/09/2019, contained no documentation of a sex offender screening and its results.
Plan of Correction:	? The Executive Director, Business Office Manager or Designee will ascertain sex offender screening and results for resident 1 and resident 3 no later than 5/29/2020. ? The Executive Director or designee will provide education for Business Office Manager on resident sex offender screening and results prior to admission and Virginia regulations to be completed by 5/29/2020. ? The Business Office Manager or Designee will perform an audit of all current resident records for sex offender screening and results to be completed by June 30, 2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new resident record for sex offender screening and results and compliance once a month for three months.
Standard #:	22VAC40-73-380-A
Description:	380-A Based on record review, the facility failed to ensure that all resident personal and social data information was obtained. EVIDENCE: 1. The personal/social data form for resident 3 did not list all known allergies for resident 3. The plan of care for resident 3 contained documentation of a peanut allergy in addition to amoxicillin, penicillin, and statins; however the peanut allergy was not listed with the other allergies on the personal/social data form for resident 3.
Plan of Correction:	? The Executive Director, Business Office Manager or Designee will ascertain resident personal and social data for resident 3 no later than 5/22/2020. ? The Executive Director or designee will provide education for Business Office Manager on resident personal and social data prior to or at date of admission and Virginia regulations to be completed by 5/29/2020. ? The Business Office Manager or Designee will audit of all current resident records for resident personal and social data to be completed by June 30, 2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new resident record for resident personal and social data and compliance once a month for three months.
Standard #:	22VAC40-73-380-B
Description:	380-B Based on record review, the facility failed to ensure that resident personal and social information shall be kept current. EVIDENCE: 1. The personal/social data forms for residents 2, 4, 5, and 9 were outdated versions; therefore, the information was not current.
Plan of Correction:	? The Executive Director, Business Office Manager or Designee will update resident personal and social data for resident 2, 4, 5 and 9 no later than 5/22/2020. ? The Executive Director or designee will provide education for Business Office Manager on resident personal and social data prior to or at date of admission and Virginia regulations to be completed by 5/29/2020. ? The Business Office Manager or Designee will audit of all current resident records for current updated resident personal and social data to be completed by June 30, 2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new resident record for current updated resident personal and social data and compliance once a month for three months.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to have full information on the services provided by hospice on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 14 dated 6/26/2019 shows that this resident receives hospice services, but they are not described in the ?Description of Services to be Provided? section of the ISP.
Plan of Correction:	? The Individualized Service Plans (ISP) for Residents 14 will be reviewed by the Health and Wellness Director, Executive Director or Designee and will be updated to reflect current identified needs, services, hospice services, who will provide services, expected outcomes and completion no later than 5/22/2020. ? The Executive Director or designee will provide education for the Health and Wellness Director and Resident Care Coordinator on Individualized Service Plans (ISP) compliance by 5/29/2020. ? The Health and Wellness Director or Designee will audit of all current residents Individualized Service Plans (ISP) for current resident identified needs/services/providers/outcomes and to ensure completion of ISP to be completed by June 30, 2020. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit current residents Individualized Service Plans (ISP) for identified resident needs and completion of ISP once a month for three months.
Standard #:	22VAC40-73-460-H
Description:	Based on document review, the facility failed to ensure that residents were bathed at least twice a week. EVIDENCE: 1. The facility ADL log shows that resident 15 was bathed or showered once during February 2020, on 2/12/2020. 2. The facility ADL log shows that resident 16 was not bathed or showered between 2/8/2020 and 2/20/2020.
Plan of Correction:	? Unable to retroactively correct February bathing schedules for resident 15 and 16. ? The Executive Director, Health and Wellness Director or Designee will update bathing schedule for resident 15 and 16 no later than 5/22/2020. ? The Executive Director or designee will provide education for Health and Wellness Director on resident personal care services and bathing schedules for residents and Virginia regulations to be completed by 5/29/2020. ? The Health and Wellness Director or Designee will audit of all current resident bathing schedules for compliance to be completed by June 30, 2020. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit all resident bathing schedules and compliance once a month for three months.
Standard #:	22VAC40-73-520-I
Description:	Based on observation, the facility failed to post a current activity schedule. EVIDENCE: 1. The activity schedule posted near the stairs on the main floor was for February, and this was observed in March.
Plan of Correction:	? The Executive Director, Resident Program Coordinator or Designee will verify the current resident activity schedule is posted no later than 5/20/2020. ? The Executive Director or designee will provide education for Resident Program Coordinator on maintaining current resident activity schedule posted for each month and Virginia regulations to be completed by 5/29/2020. ? The Executive Director, Resident Program Coordinator or Designee will audit all resident program schedules and posted areas to verify completed by 5/20/2020. ? To assist with compliance, the Executive Director, Resident Program Coordinator or Designee will visually audit each posted resident program schedule once a month for three months.
Standard #:	22VAC40-73-640-A
Description:	Based on document review and medication cart audit, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, a plan for proper disposal of medication, methods to prevent the use of outdated, damaged or contaminated medications and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order. EVIDENCE: 1. The facility?s current medication management plan states that "all medications within the community that fall under the DEA?s schedules of II-V will be counted by a licensed nurse/RMA from the off going shift and one from the oncoming shift. This procedure will occur at the beginning of each shift or whenever a change is made within that shift. Both staff?s signature and the count of bingo cards and sheets will be documented on either the Schedule II count sheet provided by the communities preferred pharmacy and the community?s controlled Medication Inventory sheet." The CONTROLLED SUBSTANCE/MAR CHANGE OF SHIFT AUDIT was missing signatures for the following dates/times; 01/01/2020 11-7 on-coming staff and 01/02/2020 7-3 off-going staff. Also missing for 11-7 on-coming shift on 01/01/2020 and 7-3 off-going shift on 01/02/2020 was the count for the number of controlled substance sheets. 2. The facility?s current medication management plan states that "medications that have been contaminated (including touched by the hand of the licensed nurse/RMA, dropped on the top of the cart, etc.) or damaged will be disposed of with a Drug Buster System of All-Purpose RX Destroyer. A licensed nurse/RMA will provide documentation of the disposed/destroyed drug on the ?Medication Destruction Log?. All controlled substances will be disposed of with a Drug Buster of All Purpose RX destroyer system in the facility?s (designated location). This disposal will be witnessed by 2 people to include either the HWD/RCC/licensed nurse or a RMA per policy. A Destruction of Controlled Medications form will be filled out completely and signed by the two witnesses. The form will be kept retained per policy." The CONTROLLED DRUG RECORD for resident 9 showed the medication Gabapentin 100MG capsule (1) was administered by staff 6 on 03/02/2020 at 8AM with a remaining amount of 14; however there was a line marked through this with ERROR and initials for staff 6. On the card for this medication were 14 Gabapentin left. Interview with staff 6 revealed that once she ?popped the pill, she realized that resident 9 was in the hospital and destroyed the pill?. Interview with staff 8 revealed that staff 6 did not properly dispose of the medication per the facility?s medication management plan. 3. The facility?s current medication management plan states that "new medication orders and order changes, must be faxed to and/or called to the pharmacy or pharmacies directly from the physician?s office. If you are taking a phone order, give the physician the appropriate pharmacy name, phone and fax numbers. Request that the physician also fax a copy to the community." Resident 1 had a physician?s order for Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth every 24 hours as needed for constipation. This medication was not available on the medication cart or in the facility. 4. On medication cart 1, there were open bottles of Polyethylene Glycol for resident 17 and resident 13, an opened bottle of Milk of Magnesia for resident 18 and an opened bottle of Mineral Oil for resident 8; none of these bottles contained when they had been opened by staff. The facility?s current medication management plan does not address methods to prevent the use of outdated medications.
Plan of Correction:	? The Executive Director, Health and Wellness Director or Designee will review medication management plan and implementation no later than 5/22/2020. ? The Executive Director will provide education for Health and Wellness Director and Resident Care Coordinator on medication management plan and implementation and Virginia regulations to be completed by 5/20/2020. ? The Health and Wellness Director or designee will provide education for all LPNs and RMAs on medication management plan and implementation and Virginia regulations to be completed by 6/5/2020. ? The Health and Wellness Director or Designee will audit all medication carts, controlled substance counts, medication administration records and plan for proper disposal of medication and Virginia state compliance to be completed by 7/13/2020. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will perform random medication management plan and medication cart audits once a month for three months.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, the facility failed to ensure that a resident who stores prescription medication in her room was allowed to do so, and kept the medication out of site. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 16 shows that this resident is unable to self-administer medication. A bottle of topical Erythromycin, a prescription antibiotic, was on top of the night stand in resident 16?s bedroom. The record for resident 16 lacks a prescription for this medication.
Plan of Correction:	? The Executive Director, Health and Wellness Director or Designee will perform resident self-administration of medication screening for resident 16, will update resident 16 UAI and ensure proper storage of medications no later than 5/22/2020. ? The Executive Director will provide education for Health and Wellness Director and Resident Care Coordinator on storage of medication, self-administration of medications and storage and Virginia regulations to be completed by 5/29/2020. ? The Health and Wellness Director or Designee will audit all current residents who self-administrator medications for medication storage and UAI for compliance to be completed by 6/31/2020. ? The Health and Wellness Director or Designee will audit all current residents who self-administrator medications for medication storage and UAI for compliance once a month for three months to ensure on-going compliance.
Standard #:	22VAC40-73-680-B
Description:	Based on audit of the medication carts, the facility failed to ensure that medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered. EVIDENCE: 1. During the audit of medication cart 1, there was a loose oblong light green pill with "45" on one side and "E" on other side and a purple/gray capsule containing OMEPRAZOLE 20 MG and R158 located in the second drawer from the top. 2. During audit of medication cart 2, there was a loose golden round gel pill containing a "Z" and two white oblong pills containing "I6" located in the bottom drawer on the left side of the cart. 3. Located on the floor by the entrance to the dining room on the first floor of the facility was a single small round yellow tab containing "L" on one side.
Plan of Correction:	? The Executive Director, Health and Wellness Director or Designee will perform medication cart audit for medication cart 1 and 2 for proper storage and medications remaining in pharmacy issued container with prescription label attached no later than 5/22/2020. ? The Executive Director will provide education for Health and Wellness Director and Resident Care Coordinator on medication cart audits, medication container or packaging, storage of medication and Virginia regulations to be completed by 5/29/2020. ? The Health and Wellness Director or Designee will provide education for all LPNs and RMAs on medication container or packaging, storage of medication and Virginia regulations to be completed by 6/5/2020. ? The Health and Wellness Director or Designee will audit all medication carts for compliance once a month for three months to ensure on-going compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on observation of the medication pass and record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The physician?s order for resident 13 dated 02/02/2020 shows ?Dapakote Tablet Delayed Release 500 MG (Divalproax Sodium) Give 1 tablet by mouth two times a day for bipolar disorder?. 2. During medication pass, this LI observed staff 6 administer resident 13 Dapakote in applesauce.
Plan of Correction:	? The Health & Wellness Director or Designee will provide education on administration of medication and administration in accordance with physician?s orders for staff 6 no later than 5/22/2020. ? The Health & Wellness Director or designee will review the physician?s orders for resident 13 no later than 5/22/2020. ? The Health & Wellness Director or Designee will audit of all current resident?s physician orders and medication administration records for appropriate medium of choice and accuracy to be completed by June 30, 2020. ? To assist with ongoing compliance, the Health & Wellness Director or Designee will audit all current resident physician?s orders and medication records once a month for three months.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to be maintained in good repair and kept clean. EVIDENCE: 1. There is a red stain in the carpet in the middle of the hall near rooms 207, 208, 209, and 210. The red stain is approximately 2 inches in diameter. 2. An upstairs bathroom off the hall on the second floor has a heavy build-up of dust in the ceiling vent.
Plan of Correction:	? The Executive Director, Maintenance Manager or Designee will clean the 2nd floor hall carpet and 2nd floor hall bathroom ceiling vent no later than 5/22/2020. ? The Executive Director or designee will provide education for Maintenance Manager and Maintenance Technician on maintenance of interior and exterior to be kept in good repair and kept clean and free of rubbish and Virginia regulations to be completed by 5/29/2020. ? The Maintenance Manager or Designee will conduct visual inspection of community common areas and hallway carpets, all community bathroom vents and Virginia regulations to be completed by 5/31/2020. ? To assist with ongoing compliance, the Maintenance Manager or Designee will conduct visual inspection of community common areas and hallway carpets, all community bathroom vents for cleanliness once a month for three months.
Standard #:	22VAC40-73-870-B
Description:	Based on observation, the facility failed to ensure that the building was well-ventilated and free from foul, stale, or musty odors. EVIDENCE: 1. The room belonging to resident 14 had a very strong urine odor.
Plan of Correction:	? The Executive Director, Maintenance Manager or Designee will inspect resident 14 apartments for ventilation and odors no later than 5/22/2020. ? The Executive Director or designee will provide education for Maintenance Manager and Maintenance Technician on maintenance of ventilation and odor reduction for resident 14 and Virginia regulations to be completed by 5/29/2020. ? The Maintenance Manager or Designee will conduct inspection of all resident apartments for proper ventilation and odors to be completed by 6/30/2020. ? To assist with ongoing compliance, the Maintenance Manager or Designee will conduct inspection of all resident apartments for proper ventilation and odors once a month for three months.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the facility failed to have the results of the most recent inspection posted. EVIDENCE: 1. Recent complaint investigations concluded in February of 2020 were not posted.
Plan of Correction:	? The Executive Director, Business Office Manager or Designee will post most recent inspection survey results per regulations in an inconspicuous location no later than 5/20/2020. ? The Executive Director or designee will provide education for Business Office Manager on posting recent inspection survey results and Virginia regulations to be completed by 5/29/2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will post each new licensing inspection survey and results per regulations within 5 days of receipt.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to obtain a sworn disclosure statement regarding criminal convictions from a new staff member. EVIDENCE: 1. The record for staff 5, hired on 1/21/2020, was lacking the sworn disclosure statement. 2. The record for staff 7, hired on 7/16/2019, was lacking the sworn disclosure statement. 3. The record for staff 8, hired on 7/25/2019, was lacking the sworn disclosure statement. 4. The record for staff 10, hired on 9/16/2019, was lacking the sworn disclosure statement. 5. The record for staff 11, hired on 11/25/2019, was lacking the sworn disclosure statement. 6. The record for staff 12, hired on 2/19/2020, was lacking the sworn disclosure statement. 7. The record for staff 13, re- hired on 12/30/2019, was lacking the sworn disclosure statement. 8. The record for staff 14, recently assigned to the facility, was lacking the sworn disclosure statement.
Plan of Correction:	? The Executive Director, Business Office Manager or Designee will ascertain sworn disclosure statements for staff 5, 7, 8, 10, 11,12,13 and 14 no later than 5/29/2020. ? The Executive Director or designee will provide education for Business Office Manager on sworn disclosure statements and Virginia regulations to be completed by 5/29/2020. ? The Business Office Manager or Designee will audit all current staff records for sworn disclosure statements to be completed by June 30, 2020. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for sworn disclosure statements and compliance once a month for three months.