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: Nov. 20, 2020 , Nov. 23, 2020 , Nov. 24, 2020 , Dec. 3, 2020 and Dec. 4, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 11-20-2020 and concluded on 12-04-2020. A complaint was received by the department regarding allegations in the areas of: Incident Reports; Individualized Service Plans; Provisions for Signaling and Call systems; Personal Care Services and General Supervision and Care, Staffing and Supervision; Food service and Nutrition; and Maintenance of Buildings and Grounds. 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 supported the allegations of non-compliance with standards or law, and violations were issued.

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure when 20 or fewer residents are present, at least two direct care staff members should be awake and on duty at all times in each special care unit who are responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member should be awake and on duty in the unit. Evidence: 1. Staff #1 stated the total number of residents in care on 09-26-2020 was ?25 residents.? 2. On 09-26-2020, the ?September Scheduled 2020? [staff work schedule] (confirmed by Staff #1), documented two direct care staff (Staff #2 and Staff #3) worked from 3:00 p.m. ? 7:00 p.m. 3. Staff #1 stated a third direct care staff person (Agency Staff #1) worked during the 3:00 p.m. ? 7:00 p.m. shift on 09-26-20; however, Staff #1 could not provide an invoice documenting the agency staff who worked. 4. Staff #1 could not provide additional documentation verifying three direct care staff worked on 09-26-2020 from 3:00 p.m. ? 7:00 p.m.
Plan of Correction:	? The Executive Director, Health and Wellness Director, or Designee will update direct care staffing work schedules to reflect Virginia required staffing ratios for a special care unit by 1/31/2021. ? The Executive Director or Designee will provide education for Health and Wellness Director and Health and Wellness Coordinator on required direct care staffing ratios and Virginia staffing regulations to be completed by 1/31/2021. ? The Health and Wellness Director, Health and Wellness Coordinator, or Designee will review direct care staffing ratios daily for one (1) month for compliance and to identify any potential training opportunities to be completed by 2/28/2021. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director, or Designee will randomly audit direct care staffing ratios and work schedules for compliance with Virginia direct care staffing rations and regulations once a month for three (3) months.
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time, to include any substitutions or other changes noted on the schedule. Evidence: 1. Staff #1 provided a copy of the staff written work schedules from 08-30-2020 through 10-07-2020. Based on the facility census, the schedules documented two out of three required direct care staff worked from 3:00 p.m. to 7:00 p.m. on 08-30-2020 and 09-27-2020; and from 11:00 p.m. to 7:00 a.m. on 10-04-2020. 2. Staff #1 provided documentation from [staffing agency] verifying the agency staff who worked. Staff #1 stated ?Agency Staff #2 worked on 08-30-2020 and 09-27-2020, and Agency Staff #3 on 10-04-2020;? however, the agency staff was not listed on the staff written work schedules. 3. The staff written work schedules did not document staff person who was in charge on 08-30-2020, 09-27-2020, and 10-04-2020 during all three shifts. 4. Staff #1 acknowledged the staff person in charge, substitutions, and other changes were not documented on the staff written work schedules during the aforementioned dates/times.
Plan of Correction:	? The Executive Director or Designee will provide education for Health and Wellness Director and Health and Wellness Coordinator on Virginia regulations on work schedules and posting of work schedules by 1/31/2021. ? The Executive Director, Health and Wellness Director, or Designee will provide education on work schedules and attendance with current clinical associates by 2/28/2021. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director, or Designee will conduct weekly audits of work schedules for one (1) month then monthly for two (2) months.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician?s instructions. Evidence: 1. Resident #5?s current signed physician?s order dated 11-05-2020 documented ?Start E.C Aspirin 325mg one po [by mouth] daily for CVA [stroke] prevention. When new ASA [Aspirin] dose arrives, D/C [discontinue] ASA 81mg.? 2. Resident #5?s November 2020 Medication Administration Record documented direct care staff administered Aspirin 81mg and Aspirin 325mg on 11-06-2020 through 11-20-2020. 3. Resident #5?s ?Progress Notes? [nursing notes] dated 11-20-2020 documented ?Call placed to [physician] in regards to medication error found. [Physician] made aware that resident had been receiving 81mg aspirin in addition to 325mg aspirin?? 4. Staff #1 acknowledged facility staff did not administer Resident #5?s Aspirin in accordance with the physician?s instructions.
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 current RMA?s no later than 2/28/2021. ? The Health & Wellness Director or designee will review the physician?s orders for resident 5 no later than 2/28/2021. ? To assist with ongoing compliance, the Health & Wellness Director or Designee will audit all current resident new physician?s orders and medication records once a month for three (3) months.