VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Staunton
1900 Hillsmere Lane
Staunton, VA 24401
(540) 885-9500

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Aug. 6, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on 08/06/21 and concluded on 08/20/20. A self-reported incident was received by the department relating to resident care . The Health and Wellness Director 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 self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review and an interview, the facility failed to have a comprehensive Individualized Service Plan (ISP) that includes the assessed needs of the resident. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident 1, dated 07/07/21 indicates resident is disoriented in all spheres, some of the time. This is not addressed on the ISP dated 07/07/21. 2. The UAI for resident 1, dated 07/07/21 indicates resident is disoriented to all spheres, some of the time. This is not addressed on the ISP dated 07/07/21. 3. The UAI for resident 1, dated 07/07/21 indicates resident needs mechanical assistance with bathing. The ISP dated 07/07/21 indicates resident is independent with bathing. 4. The UAI for resident 1, dated 07/07/21 indicates resident does not require assistance with mobility. The ISP dated 07/07/21 indicates mechanical assistance is required but does not identify the type of mechanical support used.
Plan of Correction:	1.) Unable to retroactively correct the required documentation and Plans of care such as UAI and ISP for Resident 1. Resident 1 has been discharged from facility on 8/10/2021. 2.) Re-training for staff certified to complete ISPs and UAI?s will be conducted by the Health and Wellness Director (HWD)/designee no later than 9/10/2021, to verify understanding of accuracy of assessments for the ISPs and the UAIs. 3.) The HWD/designee will conduct an audit of current residents ISP?s and UAI?s no later than September 10th 2021 to verify the ISPs and UAIs are accurate. 4.) To assist with ongoing compliance, the ISPs and UAIs will be reviewed on a random basis upon new admissions, re-admissions and residents with changes in condition on a weekly basis for 4 weeks and then on a monthly basis thereafter for 6 months by the HWD/designee.
Standard #:	22VAC40-73-460-D
Description:	EVIDENCE: 1.The incident report submitted by the facility on 07/16/21 indicates resident 1 (admitted 11/24/19) was observed walking on along the side of Churchville Avenue a two lane road, by an off duty employee around 7:00pm on 07/15/21. The report indicates resident was asked where he was going and what he was doing and he answered "I am not sure." The report indicates the resident was returned to the facility unharmed by the employee. 2. An interview with staff 1 and email correspondence received on 08/20/21 confirmed resident was last observed in the building at 6:20 walking down the hallway back towards his room. 3. According to accuweather.com, the temperature for 07/15/21 ranged from low 64 degrees to high 91 degrees. 4. The Uniform Assessment Instrument (UAI) for resident 1 dated 07/07/21 indicates resident 1 wanders at times and is disoriented in all spheres, some of the time. 5. The Individualized Service Plan (ISP) for resident 1 dated 07/07/21 indicates resident requires frequent monitoring due to recent attempts to leave facility, 1:1 and frequent monitoring. 6. Facility progress notes dated 07/06/21 at 3:34pm indicate resident has exit seeking behaviors; 06/25/21 at 9:42pm resident wandered out of the building twice. 7. The history and physical for resident 1 dated 06/22/21 indicates resident has a diagnosis of dementia and is not capable of making informed decisions. 8. Interview with staff 1 on 08/16/21 indicated staff frequently checked on the resident, but there was no documentation on file indicating this was completed.
Plan of Correction:	1.) Unable to retroactively correct the required documentation and Plans of care for Resident 1. Resident 1 has been discharged from facility on 8/10/2021. 2.) The staff will be educated on wandering/elopement of residents and documentation requirements for 1:1 monitoring and frequent check to be provided by HWD/designee on or before September 10th, 2021. 3.) HWD/designee will audit the residents? charts and conditions to validate appropriate behaviors and placement for resident?s safety by September 10, 2021. 4.) To assist with ongoing compliance the HWD/designee will review resident?s behaviors and placement for safety on a random basis upon new admissions, re-admissions and residents with changes in condition at least monthly.