VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Danville Piedmont
149 Executive Court
Danville, VA 24541
(434) 799-1930

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Dec. 11, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 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 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 12/10/2020 and concluded on 12/14/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 50. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, employee schedules, fire and health department inspections, fire drill logs and dietician oversight of special diets submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on individualized services plans (ISPs). EVIDENCE: 1. The record for resident 1 has a physician order signed 12/3/2020 for a No Added Salt diet. The ISP dated 6/5/2020 has documentation that the resident is on a regular diet and does not address the No Added Salt diet needs. 2. The ISP dated 6/19/20 for resident 3 has documentation that the resident is receiving wound care services from a home health agency but does not address the facility responsibilities/measures in place for the residents wound care needs.
Plan of Correction:	The following is Brookdale Danville Piedmont, formerly known as Abingdon Place of Danville, Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated December 3, 2018. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. Resident ISP?s will be reviewed and updated by the Health and Wellness Director (HWD)/Nurse designee to reflect the resident?s needs and preferences, and include other supports that are involved in delivery of services. HWD/Designee will review and update all resident ISPs to reflect the residents? needs and services. To assist with compliance, the HWD/designee will review the resident?s ISPs during care plan meetings held with the resident and/or responsible party, as well as during Collaborative Care meetings held bi-monthly to verify the accuracy of the assessment, as well as the documentation to include all supports that are participating in delivery of services to the resident.
Standard #:	22VAC40-73-450-D
Description:	Based on a review of resident records, the facility failed to ensure that services provided by both the facility and hospice provider are included on the individualized service plan (ISP). Evidence: 1. The ISP dated 6/5/2020 for resident 2 has documentation that the resident is receiving hospice services as ordered does not specify/detail what services are being provided by hospice to the resident.
Plan of Correction:	Resident #2 ISP will be reviewed and updated by the HWD/Nurse designee to reflect services being provided by the community and services provided by hospice. Health and Wellness Director/Designee will review and update all resident ISPs to include notes as to what services the resident is receiving and by the provider of the services. HWD/designee will review the resident?s ISPs during care plan meetings held with the resident and/or responsible party, as well as during Collaborative Care meetings held bi-monthly to verify the accuracy of the assessment, as well as the documentation to include all supports that are participating in delivery of services to the resident. To assist with ongoing compliance/Executive Director (ED)/designee will audit, monthly for three (3) months, the ISPs of all residents on hospice to verify all services are identified.
Standard #:	22VAC40-73-470-F
Description:	Based on a review of resident records, the facility failed to ensure that when a resident suffered an accident, injury or medical condition that the circumstances involved and the medical attention received was documented including the date and time of occurrence, as well as the personnel involved. EVIDENCE: 1. The record for resident 1 has documentation of the resident returning from the hospital on 9/29/2020. In an interview with staff person 4 it was noted that resident 1 went to the hospital due to a fall. The record for resident 1 does not have documentation of the circumstances involved and the medical attention received from resident 1's fall. 2. The record for resident 2 has documentation of the resident returning from the emergency room on 11/25/20. In an interview with staff person 4 it was noted that resident 1 was sent to the emergency room due to changes in their medical condition. The record for resident 2 does not have documentation of the circumstances involved and the medical attention received when the change in medical condition occurred.
Plan of Correction:	ED/designee will re-educate HWD/Resident Care Coordinator/RMAs on documentation requirements. To assist with compliance, weekly for four (4) weeks, the ED/HWD/Designee to review documentation in Resident #2?s record.