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: Aug. 13, 2021 , Oct. 19, 2021 , Oct. 20, 2021 , Oct. 28, 2021 and Nov. 8, 2021

Complaint Related: Yes

Comments:

A non-mandated complaint inspection was initiated on 8-12-21 and concluded on 11-19-21. A complaint was received by the department regarding allegations in the areas of resident care and related services, staff training and knowledge, oxygen care and training, and staff attitude. 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 licensing inspector conducted an on-site observation at the facility on 10-1-21. The evidence gathered during the investigation supported the allegations 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 in the violation notice.

Violations:

Standard #:	22VAC40-73-1140-B
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment the meets the requirements of subsection C of 22VAC40-73-1140. Evidence: 1. Staff # 3?s training record documented 9.25 hours of cognitive training, staff?s date of hire documented as 5-21-21. 2. Staff #4?s training record documented 6.7 hours of cognitive training, staff?s date of hire documented as 5-17-21. 3. Staff #5?s training record documented 9.25 hours of cognitive training, staff?s date of hire documented as 5-24-21. 4. During final exit on 11-19-21 staff #1 acknowledged staff did not have the required 10 hours of training in records presented for review.
Plan of Correction:	? Unable to retroactively correct initial training for Staff number 3 and staff number 4 as were not employed with Brookdale Virginia Beach at time of survey. ? Unable to retroactively correct initial training for staff number 5. Training scheduled for staff number 4 - (rehire) and for staff number 5. ? The Business Office Manager, Clare Bridge Program Coordinator or Designee will provide training or retraining on Cognitive impairment for staff number 4 and staff number 5 by 2/15/2022. ? The Executive Director, Business Office Manager, Clare Bridge Program Manager or Designee will provide reeducation for current direct care associates in regards to cognitive impairments in accordance with VDSS regulations by 3/28/2022. ? To assist with ongoing compliance, the Clare Bridge Program Manager or Designee will provide random observations with direct care staff monthly for three months.
Standard #:	22VAC40-73-100-C-2
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure it's infection control protocol was implemented during a blood glucose observation. Evidence: 1. During the medication observation with staff #9, resident #2's glucometer was observed to not be labeled with resident's name. 2. During the blood glucose observation staff #9 did not have a cleaned environment to place blood glucose supplies. The items used during the process were placed on the resident's bed. 3. Staff #1 informed of what was observed during the medication observation pass.
Plan of Correction:	? The Executive Director, Health and Wellness Director or Designee will provide retraining on Infection Control Program and a medication pass observation for staff number 9 by1/31/2022. ? The Executive Director, Health and Wellness Director or Designee will provide reeducation for current LPN?s, RMA?s and direct care associates in regards to the Infection Control Program by 3/28/2022. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will provide random Infection Control Program Observations with direct care staff monthly for three months.
Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit nor retain individuals with psychotropic medication without a treatment plan for three of four records . Evidence: 1. Resident #1?s May, June and July 2021 medication administration record (MAR) documented resident was administered Escitalopram Oxalate and Mirtazapine. The resident?s Order Summary document dated 5-4-21 documented the aforementioned medications. The resident?s record did not contain documentation of a treatment plan for the prescribed psychotropic medications. 2. Resident #3`s September 2021 medication administration record (MAR) documented resident is administered Effexor, Seroquel and Mirtazapine. The resident?s record did not contain documentation of a psychotropic treatment plan. 3. Resident #4?s September 2021 medication administration record (MAR) documented resident is administered Lamotrigine, Lexapro, Remeron and Trazadone. The resident?s record did not contain documentation of a psychotropic treatment plan. 4. On 11-4-21, 11-15-21 and 11-19-21 during exit interview, staff #1 acknowledged the facility did not have a treatment plan for the residents? psychotropic medications
Plan of Correction:	? Resident number 1 no longer in community. Psychotropic treatment plan present on physicians order summary for May 2021 and present in resident record at time of in person survey. Requesting consideration for removal of citation. ? Resident number 3 psychotropic treatment plan present on physicians order summary for September 2021 and present in resident record at time of in person survey. Requesting consideration for removal of citation. ? The Executive Director, Health and Wellness Director or Designee will provide education on psychotropic treatment plans in accordance with VDSS regulations with current clinical associates by 3/28/2022. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct random psychotropic treatment plan audits monthly for 2 months.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 4-9-51 documented wheeling not performed. The ISP dated 4-9-21 documented wheelchair needed as an adaptive equipment. The ISP did not document who and how the services would be provided. Stairclimbing assessed as not performed, the ISP documented resident not able to climb stairs due to unsteady gait; what services would be provided is not documented. 2. Resident #2?s UAI dated 10-1-21 documented toileting need as mechanical help/physical assistance, walking need as mechanical help/physical assistance, and mobility need as physical and mechanical assistance. The ISP dated 10-1-21 did not identify what specific mechanical assistance was required or needed. A wheelchair and walker were observed in the resident?s room during site visit. Stairclimbing need assessed as not performed. The ISP did not document who and how the services would be provided when needed. 3. Resident #3?s Active Medication List updated 9-24-21 documented resident allergic to the following: (a) Fenofibrate, micronized (b) Simvastatin and (c) Lisinopril. These medications were not documented on resident?s ISP dated 6-8-21. The UAI dated 6-8-21 documented wheeling and stairclimbing not performed. The ISP did not document what staff would do to provide services. Mobility assessed as mechanical assistance and supervision. The ISP did not document what specific mechanical assistance was required or needed. A wheelchair and walker was observed in resident?s room during site visit. 4. Resident #4?s UAI dated 10-9-21 documented bathing need as mechanical help and physical assistance. The ISP dated 10-9-21 did not identify what specific mechanical device was required or needed. Stairclimbing assessed as not performed, the ISP did not document how staff would provide services for assessed need. 5. During exit meetings staff #1 acknowledged all assessed needs for residents #1, #2, #3 and #4 were not documented on the residents? ISPs.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/30/2021. 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. ? Resident number 1 and resident 4 no longer in community. ? The Individualized Service Plans (ISP) for Resident number 2 and resident umber 3 will be reviewed by the Executive Director, Health and Wellness Director or Designee and will be updated to reflect current identified needs, services, who will provide services, expected outcomes and completion no later than 12/31/2021. ? The Executive Director will provide education for the Health and Wellness Director and Health and Wellness Coordinator on Individualized Service Plans (ISP) compliance by1/31/2022. ? The Health and Wellness Director or Designee will audit of all current residents Individualized Service Plans (ISP) for current resident identified needs/services/providers/outcomes and to ensure completion of ISP to be completed by 3/28/2022. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit three (3) current resident charts Individualized Service Plans (ISP) for identified resident needs and completion of ISP once a month for three months.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on record review, staff interview and collateral interview, the facility failed to ensure the resident?s individualized service plan (ISP) was reviewed and updated as the resident?s condition changed . Evidence: 1. Interview with staff members and collateral interview, stated resident #1?s activities of daily living (ADL) declined after admission to the facility on 4-9-21 and return from hospital. According to interviews, resident was able to walk and was able to go to the bathroom. The resident?s uniform assessment instrument (UAI) and ISP dated 4-9-21 documented resident was independent with toileting, bowel and bladder. According to staff interviews the resident became incontinent of bowel and bladder. Resident?s Progress Notes documented resident?s incontinence and skin breakdown: (a) 5-15-21, ?resident now becoming incontinent, resident covered in urine and feces? (b) 6-15-21, ?resident fully incontinent? and (c) 6-18-21, ?representative notified to provide briefs for incontinent care?. Progress notes documented skin breakdown:(a) 6-13-21, ? an opened area noted on left buttocks and it was bleeding?, during adl care measurements noted and information documented on skin integrity sheet (b) 6-15-21, resident ?showing signs of breakdown on bottom (right side)?, resident has ? quarter size reddened area to right buttocks and skin in abraded, notification for home health care? and (c) 6-25-21 ?open area on right buttock cheek?. 2. Resident #1?s June 9, 2021 Order Summary Report documented resident to use wheelchair for ambulation. Resident?s Progress Note documented, (a) 5-20-21, 5-22-21, ?resident unable and unwilling to walk to scale? staff requesting an alternate order (b) staff and collateral interviews stated resident?s shortness of breathing made it difficult for resident to walk. The resident physician?s order documented needed Oxygen continuously. 3. Staff #1 acknowledged resident?s care needs not updated on the UAI and ISP.
Plan of Correction:	? Resident #1 no longer in community ? The Health & Wellness Director or Designee will provide education to LPNs, RMAs, and Caregivers on updating ISP as changes occurs by 1/31/2022. ? The Health & Wellness Director or Designee will audit all current resident Individualized Service Plans by 3/28/2022. ? To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan chart audits monthly on 3 resident charts for two (2) months.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. Resident #1?s May 4, 2021 and June 9, 2021 Order Summary Report documented resident?s medication Tiotropium Bromide Monohydrate Capsule 18 MCG (Spiriva) order dated 4-9-21. Progress Notes documented the facility not having the medication in the facility: (a) 4-13-21, awaiting pharmacy, (b) 4-22-21, staff contacting pharmacy (c) 4-23-21, staff documented will order, (d) 5-13-21, awaiting pharmacy, (e) 5-14-21, needs attention from HDW (Health and wellness director) (f) 5-15-21, awaiting pharmacy, staff will call pharmacy (g) 5-16-21, medication not available and 5-20-21, Health and Wellness Director (HWD) action needed. 2. Resident #1?s May and June 9, 2021 Order Summary Report documented resident?s medication Anoro Ellipta Aerosol Powder Breath Activated 62.5-25MCG/INH (Umeclidinium-Vilanterol) order dated 4-9-21. Progress Notes documented medication not available: (a) 5-10-21, not in cart, will order (b) 5-12-21, awaiting pharmacy will give a call (c) 5-15-21, waiting on pharmacy, will call to check on it and (d) 5-17-21 Anoro Ellipta Aerosol Powder Breath Activated 62.5-25MCG/INH medication discontinued. There was no physician order provided for discontinuation of medication. The resident?s July 7, 2021 Order Summary Report documented the Anoro Ellipta Aerosol Powder Breath Activated 62.5-25MCG/INH order date 6-17-21. (e) Progress Notes dated 6-20-21, documented medication not on cart, different dose dated (f) 6-21-21 documented facility awaiting medication from pharmacy. 3. During exit meeting, staff stated resident no longer in facility
Plan of Correction:	? Resident number 1 is no longer in community. ? The Executive Director, Health & Wellness Director or Designee will provide reeducation on Medication Management Plan for current LPNs and RMA?s no later than 3/28/2022. ? The Health & Wellness Director or designee will audit the medication administration orders for three residents no later than 3/28/2022. ? To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will audit 10 current resident medication administration records once a month for three months.
Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. Resident 1?s April and May 2021 medication administration record (MAR) documented Furosemide 20 mg for three days and May 2021 MAR documented Furosemide 20 mg daily, starting on 5-13-21. May 2021?s MAR documented Amoxicillin 500mg four times a day, starting 5-19-21. The June 2021 MAR documented Amoxicillin 500 mg four times a day until surgery 6-19-21, medication started 6-12-21 and stopped on 6-19-21. The May 2021 also documented Bactrim DS 800-160 MG for seven days. No physician?s order was provided for the aforementioned medications. 2. During the exit Staff #1 acknowledged facility did not provide or have physician?s orders for resident #1?s medications.
Plan of Correction:	? Resident number 1 is no longer in community. Physician orders present in resident record at time of survey. Requesting reconsideration for removal of citation. ? The Health & Wellness Director or Designee will provide reeducation on physician?s or other prescriber?s order for current LPNs and RMA?s no later than 3/28/2022. ? To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will audit all current resident new physician?s orders and medication records once a month for three months.
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure the physician or prescriber?s orders identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #3?s Active Medications List dated 9-24-21 did not include the diagnosis, condition, or specific indications for administering the following medications: (a) Amlodipine (b) Loratadine (c) Niacin (d) Coreg (f) Namenda and (g) Esbriet. 2. Staff #1 acknowledged during exit, resident?s physician?s order did not document the diagnosis, condition, or specific indications for administering each drug.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure the resident?s medication was administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing Evidence: 1. Resident #1?s June 6, 2021 Order Summary Report document Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/NH (Fluticasone Furoate-Vilanterol) was discontinued on 6-26-21. The June medication administration (MAR) record did not document medication?s discontinuation, staff initials documented medication continued to be administered for the month of June 2021. The resident?s July 2021 MAR also documented the resident received the medication on 7-1-21 and 7-2-21. 2. During the exit meeting staff #1 informed of information documented on the resident?s MAR and Progress notes.
Plan of Correction:	? Resident #1 no longer in community ? The Health & Wellness Director or Designee will provide reeducation on administration of medication and administration in accordance with physician?s orders for current RMA?s no later than 2/15/2022. ? The Health & Wellness Director or designee will review the physician?s orders for three residents no later than 2/15/2022. ? To assist with ongoing compliance, the Health & Wellness Director or Designee will audit all current resident new physician?s orders and medication records once a month for three (3) months
Standard #:	22VAC40-73-700-5
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that all direct care staff responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment. Evidence: 1. Staff members #4, #5 and #7 did not have documentation of oxygen training. Staff were responsible for assisting resident #1 with oxygen supplies and care. Resident #1 required to have oxygen via nasal cannula continuously. The facility?s oxygen policy CS-40-18 documented staff should be trained to assist with resident?s oxygen. The policy also documented the resident?s need for oxygen should be documented on the resident?s service plan. 2. During the exit staff #1 was reminded of staff being training according to the needs of the training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by the resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. Evidence: 1. During a tour of the facility, the vent in the bathroom of room #15 was covered with light grey substance; the bathroom toilet seat and commode is twisted toward the wall; the base of the commode is missing the covering, exposing an approximately 1 in screw. The dresser is missing the front portion of the drawers in room #15. 2. Staff #1 acknowledged the furnishings and ceiling vent were not in good condition.
Plan of Correction:	? Resident no longer in community. ? Dust removed from bathroom vent, re-caulked around commode on floor and replaced caps to cover screw in room #15. ? The Executive Director or Designee will provide reeducation for the housekeeping staff and caregiver staff on reporting maintenance and grounds repairs needed to be completed by 2/15/2022. ? The Maintenance staff or designee and care staff will make apartment checks for commode screw caps and bathroom vents for good repair completed by 2/15/2022. ? The Maintenance staff or designee and care staff will randomly audit current resident?s commodes for screw caps and bathroom vents for good repair and compliance once a month for three months.