VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 13, 2020

Complaint Related: Yes

Areas Reviewed:

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on May 13, 2020 and concluded on May 13, 2020. A complaint was received by the department regarding allegations in the areas of admission retention and discharge of residents, resident care and related services, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing representative reviewed resident records, documentation regarding buildings and grounds, and conducted interviews. The following was discussed: documentation of fall interventions, and documenting resident behaviors. The complaint is not valid. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please review, sign, date, and return the Violation Notice, Supplemental, and Summary pages to include your facility's plan of corrections. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice in a Word document and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. Additionally, please contact me if you would like to review your Violation Notice via phone.

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the fall risk rating was updated after a fall. Evidence: 1. Resident #1 had a fall on 03-28-20 according to resident?s most current Individualized Service Plan (ISP); however, no fall risk rating was completed. 2. Staff #1 acknowledged fall risk ratings were not updated after resident #1's falls.
Plan of Correction:	1. On the day of the inspection, fall risk rating of Resident #1 was available and identified that the record was complete. Due to the timed ?desk review inspection,? facility was not able to provide the copies within the allocated time frame. 2. Executive Director or Designee will provide education for Health and Wellness Director/Resident Care Coordinator on fall risk ratings and Virginia regulations by 5/28/2020. 3. Health and Wellness Director or Designee will provide education to all nursing staff on fall risk ratings and record keeping by 6/2/2020. 4. Health and Wellness Director or Designee will audit current resident records for fall risk ratings by 6/30/2020. 5. To assist with ongoing compliance, the Health and Wellness Director or Designee will audit all current resident record of initial training for compliance with Fall risk ratings once a month for three months.