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 26, 2020 , June 29, 2020 and June 30, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Criminal History Record Report

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 renewal inspection was initiated on 06-26-2020 and concluded on 06-30-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 31. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliance's with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record review and interview, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the administrator or designee determined whether placement in the special care unit was appropriate and maintained documentation of the justification in the resident's record. Evidence: 1. Resident #1 admitted to the special care unit on 02-19-2020 and resident #3 admitted to the special care unit on 02-06-2020 (physical move in date was 02-18-2020). 2. Staff #2 stated the facility?s determination and justification is documented on the ?ED letter;? however, staff #2 did not provide documentation of the facility?s determination and justification for resident #1 and resident #2 being placed in the special care unit. 3. Staff #2 acknowledged the facility did not document the determination and placement for resident #1 and resident #2 to be placed in the special care unit.
Plan of Correction:	1. Unable to retroactively correct documentation of determination at move in for resident #1 and #2. 2. Executive Director or Designee will complete current documentation of determination for resident #1 and #2 by 7/10/2020. 3. The Executive Director or Designee will audit 5 random resident records for documentation of determination monthly for 3 months to ensure appropriate placement in the special care unit has been documented. 4. The Executive Director or Designee will review all new resident files prior to day of move in to ensure the determination is completed and in the new resident record.
Standard #:	22VAC40-73-210-G
Description:	Based on staff record review and interview, the facility failed to document the entity that provided the training and the number of hours of training in the staff record. Evidence: 1. Staff #2 provided a copy of staff #5?s annual training dated 08-17-2018 through 08-18-2019. The annual training did not include the entity that provided the training or the number of hours of training. 2. Staff #2 acknowledged staff #5?s record did not include documentation of the entity that provided the training or the number of hours of training.
Plan of Correction:	1. The Executive Director or Designee will educate the Business Office Coordinator to include the entity providing the training as well as track the number of hours of training for each associate 2. The Business Office Coordinator or Designee will ensure that each associates training hours have the entity and number of hours listed in their training log 3. The Business Office Coordinator or Designee will audit training logs and hours of 5 associate per month to assist with compliance of Virginia regulation requirements
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed whenever there is a significant change. Evidence: 1. Resident #1?s current Individualized Service Plan (ISP) dated 02-20-2020 documented the resident ?requires staff to assist with cleaning? for toileting. The current UAI dated 02-12-2020 documented the need for supervision only with toileting. The UAI was not updated to reflect the need for physical assistance with toileting. 2. Resident #2?s current ISP dated 07-01-2019 documented the resident uses a ?shower chair, shower/bath mat, grab bars? for bathing and uses a ?raised toilet seat? for toileting. The current UAI dated 07-01-2019 documented the need for supervision only with bathing and documented the resident did not need assistance with toileting. The UAI was not updated to reflect the need for mechanical and supervision with bathing or the need for mechanical assistance for toileting. 3. During interview on 06-26-2020, staff #1 acknowledged resident #1 and resident #2?s UAI?s were not updated to reflect the resident?s needs per the ISP?s.
Plan of Correction:	1. The Executive Director or Designee will educate the Health and Wellness Director to update the UAI and the ISP together to ensure that needs are addressed appropriately. 2. The Health and Wellness Director or Designee corrected resident #1 and #2 UAI to reflect the need addressed on the ISP. 3. The Health and Wellness Director or designee will conduct random audits of ISP?s and UAI?s monthly for 3 months to assist with compliance of Virginia regulation requirements
Standard #:	22VAC40-73-940-A
Description:	Based on document review and staff interview, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Report of the inspection should be retained at the facility for at least two years. Evidence: 1. On 06-26-2020, staff #1 provided a copy of the facility?s annual fire inspection dated 08-17-2017. 2. Staff #2 and staff #3 could not provide documentation of an annual fire inspection report for 2018 or 2019, or documentation of correspondences with the fire official documenting the reason for the delay of the annual fire inspections. 3. Staff #2 and staff #3 confirmed the fire inspection dated 08-17-2017 and acknowledged the facility did not have an annual fire inspection since 08-17-2017.
Plan of Correction:	1. The Executive Director or Designee will arrange for the appropriate fire official to complete the annual Fire Inspection. 2. The annual Fire inspection will be completed by July 31, 2020 or sooner per the fire official?s schedule. 3. The Executive Director or Designee will maintain a file to ensure the Fire inspection is completed annually to assist with compliance of Virginia regulation requirements.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #1 provided a list of newly hired staff and dates of hire (labeled ?Seniority date?), which included staff #1?s date of hire on 12-30-2019. 2. Staff #1?s orientation documented the first day of work was 12-30-2019. Staff #1?s criminal history record report was dated 01-13-2020, and was not obtained on or prior to the 30th day of staff #1?s employment. 3. Staff #2 stated the facility did not have documentation of an Administrative staff schedule and acknowledged staff #1?s criminal history record report was not obtained on or prior to the 30th day of staff #1?s employment.
Plan of Correction:	1. The Executive Director or Designee will educate the Business Office Coordinator on the requirement for criminal history record reports for all new associates. 2. All new associates will have a criminal history report completed 30 days prior to or the day of hire. 3. The Business Office Coordinator or Designee will randomly audit 5 associate files for criminal history reports per month to assist with compliance of Virginia regulation requirements 4. The Business Office Coordinator will post the Administrative staff schedule monthly