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: May 4, 2021 , May 6, 2021 and May 7, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 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 renewal inspection was initiated on May 4, 2021 and concluded on May 7, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 26. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, menus, activities calendar, staff schedules, healthcare oversight, health and fire inspections, criminal record and sworn disclosure checks 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 #:	22VAC40-73-320-A
Description:	Based on record review and discussion, the facility failed to ensure a person had a physical examination within 30 days preceding admission. Evidence: 1. Resident #1?s physical examination was dated 11-30-2020; however, the resident admitted 02-18-2021. There was no statement from the physician indicating that there were no changes to the examination. 2. Staff #1 and staff #2 confirmed during discussion that the physical examination was not within 30 days preceding admission.
Plan of Correction:	The Executive Director, Sales Manager or Designee will ascertain resident physical examination within 30 days of admission moving forward from 6/3/2021. The Executive Director or designee will provide education for the Sales Manager on resident physical examination prior to admission and Virginia regulations to be complete by 7/30/2021. To assist with ongoing compliance, the Executive Director, Sales Manager or Designee will review all new resident record for physical examination prior to admission and compliance once a month for three months.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and discussion, the facility failed to ensure methods that each resident?s prescription medications are refilled in a timely manner to avoid missed dosages. Evidence: 1. Resident #1?s ?Progress Notes? documented the following medications were not refilled in a timely manner to avoid missed dosages 19 times from January 2021 to April 2021: a. Effexor XR 150 mg: 02-26-2021, 02-27-2021, b. Magnesium Oxide 500 mg: 01-25-2021, 02-07-2021, 02-09-2021, 02-20-2021, 03-06-2021, c. B Complex: 01-27-2021, 01-28-2021, 01-29-2021, d. Pimavanserin Tartrate 34 mg: 02-09-2021, 02-13-2021, 04-17-2021, e. Protonix 40 mg: 02-11-2021, 02-16-2021, f. Aspirin 81 mg: 02-13-2021, 03-12-2021, g. Rasagiline Mesylate: 0.25 mg 02-12-2021, and h. Cholecalciferol Tab 1000u 04-14-2021. 2. Staff #2 confirmed during discussion Resident #1?s medications were not refilled in a timely manner to avoid missed dosages.
Plan of Correction:	The Executive Director, Health and Wellness Director or Designee will review medication management plan and implementation no later than 7/12/21. The Executive Director will provide education for Health and Wellness Director and Health and Wellness Coordinator on medication management plan and implementation and Virginia regulations to be complete by 7/12/2021. The Health and Wellness Director or designee will provide education for all RMAs on medication management plan, implementation, and Virginia regulations to be complete by 7/30/2021. The Health and Wellness Director or Designee will audit all medication carts, controlled substance counts, medication administration records and plan for proper disposal of medication and Virginia state compliance to be completed by 7/16/2021. To assist with ongoing compliance, the Health and Wellness Director or Designee will perform random medication management plan and medication cart audits once a month for three months.