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: June 1, 2021 , June 2, 2021 , June 4, 2021 , June 7, 2021 and June 8, 2021

Complaint Related: Yes

Areas Reviewed:

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 6/1/21 and concluded on 6/8/21. A complaint was received by the department regarding allegations in the area of resident care and related services. 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 allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was updated as needed for a significant change in a resident?s condition. Evidence: 1. Resident #1?s UAI dated 5/2/21 documented resident needs human-help physical assistance for dressing and transferring; however, ISP dated 10/9/2020 documented resident needs supervision for dressing and is independent with transferring. 2. Staff #1 acknowledged Resident #1?s ISP dated 10/9/2020 was not updated to reflect current needs for dressing and transferring.
Plan of Correction:	? The Health & Wellness Director or Designee for resident #1 will review charts and conduct assessments on resident to update changes in resident needs for supervision for dressing and transferring for two weeks until August 81h, 2021 to ensure changes were recorded and changed. ? The Health & Wellness Director or Designee will continue to review ISP policies and to update changes on ISP as they occur. ? To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan chart audits monthly on resident #I for two (2) months ending on September 26, 2021.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to make and document rounds no less than every two hours for each resident with an inability to use the signaling device. Evidence: 1. Resident #1?s current Individualized Service Plan (ISP) dated 10/9/2020 documented due to cognitive impairment, may not remember to use signaling. Staff to provide rounds every two hours when asleep for safety and care needs. 2. Resident #2?s current ISP dated 11/19/2020 documented resident is unable to use the call light system. Staff will complete visual checks every two hours during hours of sleep for safety and care needs. 3. Resident #3?s admission date is 5/1/21 and his current ISP dated 5/1/21 documented due to cognitive impairment, may not remember to use signaling. Staff to provide rounds every two hours when asleep for safety and care needs. 4. Staff #1 could not provide documentation of ?VA Night Check and Special Surveillance Record? for resident #1, resident #2, or resident #3 for the month of May 2021; and acknowledged that documentation could not be provided.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/1/2021. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to the delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. ?The Health & Wellness Director or Designee will ensure that rounds are conducted on resident # l, #2 and #3 ever)' two hours. A two hour check book has been implemented for all residents and staff will conduct the 2 hour checks. Staff will place their initial on the form to ensure the checks were completed. The Health & Wellness Director or Designee will follow up each morning to ensure the two hour checks were completed. ? The ED or designee will do a daily audit to ensure checks are being completed for two weeks until August 8th 2021.