VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Salem
2001 Ridgewood Drive
Salem, VA 24153
(540) 494-8594

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: April 26, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Sworn Statement or Affirmation 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 4/26/2021 and concluded on 4/27/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 57. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight submitted by the facility to ensure documentation was complete. 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 #:	22VAC40-73-440-A
Description:	440-A Based on record review, the facility failed to ensure that the uniform assessment instrument shall be completed whenever there is a significant change in the resident?s condition. EVIDENCE: 1. The UAI for resident 3, dated 2/16/2021, indicated that the resident is abusive/aggressive/disruptive weekly or more with the type of inappropriate behavior listed as ?verbally disruptive, exit seeks, curses staff, disruptive, frustrates easily?. 2. Progress notes for resident 3 noted 11 instances of physically aggressive behavior from resident 3 toward staff members or other residents for the following dates: 2/24/2021, 2/26/2021, 3/6/2021, 3/14/2021, 3/23/2021, 3/25/2021, 3/27/2021, 3/28/2021 one incident documented at 6:08 PM and another incident documented at 6:17 PM, 4/15/2021, and 4/17/2021; however, the UAI was not updated to address this significant change.
Plan of Correction:	? The Uniform Assessment Instrument (UAI) for Resident 3 will be reviewed by the Health and Wellness Director, Executive Director or Designee and will be updated to reflect current physically aggressive behavior towards staff members, or other residents. Expected outcomes and completion no later than 05/09/2021. ? The Executive Director or designee will provide education for the Health and Wellness Director on Uniform Assessment Instrument (UAI) compliance by 05/16/2021. ? The Health and Wellness Director or Designee will perform an audit of all current residents Uniform Assessment Instrument (UAI) for current resident behaviors, including abusive, verbally disruptive, and physically aggressive and exit seeking behaviors with outcomes and to verify completion of UAI to be completed by May 30, 2021. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit current residents Uniform Assessment Instrument (UAI) for identified resident behaviors and completion of UAI once a month for three (3) months.
Standard #:	22VAC40-73-450-D
Description:	450-D Based on record review, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 4, dated 7/1/2020, was updated on 12/8/2020 to indicate that the resident was receiving Good Samaritan hospice services; however, the ISP did not indicate which services that hospice was providing.
Plan of Correction:	? The individualized Service Plans (ISP) for Resident 4 will be reviewed by the Health and Wellness Director, Executive Director or Designee and will be updated to reflect current identified needs, services, hospice services, who will provide services, expected outcomes and completion no later than 05/09/2021. ? The Executive Director or designee will provide education for the Health and Wellness Director on Individualized Services Plans (ISP) compliance by 05/16/2021. ? The Health and Wellness Director or Designee will perform an audit of all current residents Individualized Service Plans (ISP) for current resident identified needs/services/providers/outcomes and to verify completion of ISP to be completed by May 30, 2021. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit current residents Individualized Service Plans (ISP) for identified resident needs and completion of ISP once a month for three (3) months.
Standard #:	22VAC40-73-450-F
Description:	450-F Based on record review, the facility failed to ensure that individualized service plans (ISP) shall be reviewed and updated as the condition of the resident changes. EVIDENCE: 1. The ISP for resident 3, dated 2/16/2021, indicated a description of needs as ?aggressive behavior? with an identified date of 2/16/2021. This ISP also indicated the description of services to be provided that the resident is ?abusive, verbally disruptive, and exit seeks weekly or more, and staff will redirect resident with dignity and respect?. 2. Progress notes for resident 3 noted 11 instances of physically aggressive behavior from resident 3 toward staff members or other residents for the following dates: 2/24/2021, 2/26/2021, 3/6/2021, 3/14/2021, 3/23/2021, 3/25/2021, 3/27/2021, 3/28/2021 one incident documented at 6:08 PM and another incident documented at 6:17 PM, 4/15/2021, and 4/17/2021; however, the ISP was not updated to address this significant change.
Plan of Correction:	? The individualized Service Plans (ISP) for Resident 3 will be reviewed by the Health and Wellness Director, Executive Director or Designee and will be updated to reflect current physically aggressive behavior towards staff members, or other residents. Expected outcomes and completion no later than 05/09/2021. ? The Executive Director or designee will provide education for the Health and Wellness Director on Individualized Services Plans (ISP) compliance by 05/16/2021. ? The Health and Wellness Director or Designee will perform an audit of all current residents Individualized Service Plans (ISP) for current resident behaviors, including abusive, verbally disruptive, physically aggressive and exit seeking behaviors with outcomes and to verify completion of ISP to be completed by May 30, 2021. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit current residents Individualized Service Plans (ISP) for identified resident behaviors and completion of ISP once a month for three (3) months.
Standard #:	22VAC40-90-30-B
Description:	22VAC40-90-30 Based on record review, the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. EVIDENCE: 1. Documentation for staff 6 indicated a hire date of 7/29/2020, and the sworn disclosure statement (SD) was completed on 4/25/2021. 2. Documentation for staff 9 indicated a hire date of 9/30/2020, and the SD was completed on 4/26/2021. 3. Documentation for staff 10 indicated a hire date of 4/10/2020, and the SD was completed on 4/25/2021. 4. Documentation for staff 11 indicated a hire date of 4/3/2020, and the SD was completed on 4/25/2021.
Plan of Correction:	? The Executive Director or designee will provide education for Business Office Manager on sworn disclosure statements and Virginia regulations to be completed by 5/30/2021. ? The Business Office Manager or Designee will audit all current staff records for sworn disclosure statements to be completed by May 30, 2021. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for sworn disclosure statements and compliance once a month for three months.
Standard #:	22VAC40-90-40-B
Description:	22VAC40-90-40 Based on record review, the facility failed to ensure that the criminal history record report (CRC) shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Documentation for staff 5 indicated a hire date of 9/16/2020, and the CRC results were dated 4/17/2021. 2. Documentation for staff 6 indicated a hire date of 7/29/2020, and the CRC results were dated 4/24/2021. 3. Documentation for staff 7 indicated a hire date of 10/16/2020, and the CRC results were dated 4/24/2021. 4. Documentation for staff 8 indicated a hire date of 1/11/2021, and the CRC results were dated 4/24/2021.
Plan of Correction:	? The Executive Director or designee will provide education for Business Office Manager on Criminal History Records and Virginia regulations to be completed by 5/30/2021. ? The Business Office Manager or Designee will audit all current staff records for Criminal History Records to be completed by May 30, 2021. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for Criminal History Records and compliance once a month for three months.