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: May 18, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS

Technical Assistance:

930-D

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 5/18/2021 and concluded on 6/23/2021. A complaint was received by the department regarding allegations in the areas of resident care and supervision. 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 did not support the allegation of non-compliance with standards or law.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	70-A Based on record review, the facility failed to ensure that a report was made to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. Progress notes for resident 1, dated 12/17/2021, indicated that the resident returned from Lewis Gale Hospital with an apparent hematoma to the right side of her head due to a previous fall. An incident report was not received by Licensing regarding this fall with head injury. 2. Progress notes for resident 1, dated 1/21/2021, indicated that the resident was found lying in the floor at bedside with a red area to the left cheek and a large hematoma to the back of her head for which the resident was transferred to Roanoke Memorial Hospital for evaluation. An incident report was not received by Licensing regarding this fall with head injury. 3. Progress notes for resident 1, dated 4/21/2021, indicated that the resident had an unwitnessed fall around 1:00 AM and was found by her CNA to have bleeding from the head and nose with a significant amount of blood surrounding her. As a result, the resident was transported to Lewis Gale Hospital for treatment and returned on the same date. An incident report was not received by Licensing regarding this fall with head injury.
Plan of Correction:	The Health and Wellness Director or Designee will ensure that a report will be made to the regional licensing office within 24 hours of any major incident that has negatively affected or threatens the life, health, safety, or welfare of any resident. The Executive Director (ED) or designee will provide education for the Health and Wellness Director and or designee on state reportable incident compliance by 7/5/2021. The Health and Wellness Director or designee will keep a binder record of all reportable incidents, along with supportive documentation to reflect date and time of notifications. This binder will be kept current for three months. The ED will audit binder weekly x 4 weeks then monthly x 3 months, then as needed as part of the QA process.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	325-B Based on record review, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall. EVIDENCE: 1. The individualized service plan (ISP) for resident 1, dated 8/27/2020, indicated that the resident was a high fall risk and was later updated to indicate that falls occurred on 10/29/2020, 12/16/2020, 1/21/2021, 1/23/2021, 1/28/2021, and 4/21/2021; however, there were no fall risk ratings completed for the 12/16/2020, 1/21/2021, 1/28/2021, and 4/21/2021 falls.
Plan of Correction:	Unable to retroactively correct the ISP due to resident currently no longer residing at Brookdale Salem. Moving forward, fall risk ratings after each fall will be completed. The Executive Director (ED) or designee will provide education for the Health and Wellness Director and/or designee on fall risk ratings compliance by 7/5/2021. The Health and Wellness Director or designee will perform an audit of all current residents' fall risk ratings to be completed by 7/30/2021. To assist with ongoing compliance, the Health and Wellness Director or designee will randomly audit current residents' fall risk ratings once a month for three months.
Standard #:	22VAC40-73-325-C
Complaint related:	Yes
Description:	325-C Based on record review, the facility failed to ensure that should a resident who meets the criteria for assisted living care fall the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls. EVIDENCE: 1. The ISP for resident 1, dated 8/27/2020, indicated that the resident was a high fall risk and required fall management by staff. The ISP indicated initial interventions by staff which included that the resident will be redirected by staff, ensure proper foot wear is on, clutter is moved out of the way, and scatter rugs are not in place. 2. Despite the initial listed interventions by staff to prevent falls, resident 1 had documented falls on 10/29/2020, 12/16/2020, 1/21/2021, 1/23/2021, 1/28/2021, and 4/21/2021; however, the record for resident 1 contained no documentation of additional measures to reduce the risk of or prevent subsequent falls.
Plan of Correction:	Unable to retroactively correct the individualized service plan (ISP) due to resident no longer residing at Brookdale Salem. Moving forward, all fall risk interventions and ratings will be included on ISP and updated with each fall. The Executive Director (ED) or designee will provide education for the Health and Wellness Director and/or designee in ISPs and fall risk interventions compliance by 7/5/2021. The Health and Wellness Director or designee will perform an audit of all current residents' ISPs for current resident fall risk interventions, and to verify and monitor for completion of ISP. This will be completed by 7/30/2021. To assist with ongoing compliance, the Health and Wellness Director or designee will audit current residents' ISPs randomly for fall risk interventions and ratings of ISPs once a month for three months, and as needed, based on audit findings.