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: June 11, 2020 and June 12, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 06-11-2020 and concluded on 06-12-2020. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services. 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 evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Staff #1 provided copies of the staff ?Progress Notes? which documented the following: A. On 05-27-2020, resident #2 had ?a fall today in activity room at 4:30. Per aide, resident was being pushed down to dinner when she leaned forward and fell out of her chair. Resident has a bruise to right forehead as well as swelling?? B. On 05-10-2020, resident #3 had ?swelling and bruise around Lt. eye.? C. The aforementioned incidents involving resident #2 and resident #3 were not reported to the regional licensing office within 24 hours. 2. Staff #1 acknowledged the aforementioned incidents involving resident #2 and resident #3 were not reported to regional licensing office within 24 hours.
Plan of Correction:	1.On the day of the inspection an immediate audit of incident reporting system and nurses notes of resident #1 and resident #2 completed and findings reviewed during the quality assurance meeting. On 6/10/2020, Executive Director provided education for the Health and Wellness Director/Resident Care Coordinator on the VDSS standards and facility?s incident reporting forms, policy and procedures. 2. Facility?s incident reporting procedure will be reviewed by Health and Wellness Director/Resident Care Coordinator/designee and nursing staff will be re-educated on reporting protocol and Virginia regulations by the Executive Director. 3. The District Director of Operations/designee will provide re-education for Executive Director and District Director of Clinical Services/designee will provide re-education for Health and Wellness Director, Resident Care Coordinator/Designee on reporting timely and preparing any reportable incident in compliance with the regulations to the licensing office by 07/26/2020. 4. To assist with ongoing compliance, the Executive Director/Health and Wellness Director/ Resident Care Coordinator or Designee will randomly audit current resident records for compliance once a month for three (three) months.