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: Jan. 21, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

440-A, 870-A

Comments:

The licensing inspector accompanied by another licensing inspector conducted an unannounced inspection in response to a complaint that was received by the licensing office on 1/20/2022. The LIs reviewed documentation, toured the facility, and conducted interviews relating to allegations in the areas of facility policy, medication management, physical plant issues, and resident care and services. The information gathered during the investigation supports some of the allegations. Based on the preponderance of evidence the complaint is determined to be valid. Any violations found that are unrelated to the initial allegations can also be found on the violation notice. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-1180-B
Complaint related:	Yes
Description:	1180-B Based on record review, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. During a guided walk-through of the facility?s safe secure unit by staff 1 and staff 2 on 1/21/2022 at approximately 1:00 PM, LI and collateral 1 opened the cabinets under the sink that is in the corridor outside of resident 1 room. As a result, two LIs pulled out a basket of toiletries which contained the following potentially hazardous items: Total Body Foam Cleanser, Schick Disposable Twin Blade Razors, Arm & Hammer Ultra Max deodorant, Schick Hydro Sensitive Shave Gel, Derma Daily Moisturizing Lotion, Axe Body Spray, Aveeno Daily Moisturizing lotion, and VO5 Daily Shampoo. In addition, the unlocked drawer below the counter contained a roll of plastic trash bags.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem Virginia regarding the Statement of Deficiencies date 01/21/2022 but received 02/07/2022. 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 regulatory requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Executive Director, Maintenance Director, and Health and Wellness Director immediately completed a full sweep of memory care unit on January 21, 2022 with remaining safety locks removed from cabinets and all personal hygiene and chemical products stored in secured location. 2. The Health and Wellness Director or designee will provide education for current LPNs, RMAs, and caregivers in memory care unit regarding proper securing of chemicals in memory care and room sweep to be completed by March 31, 2022. 3. To assist with on-going compliance, the Health and Wellness Director or designee will conduct random room sweeps weekly in the memory care unit for three months with 25% of rooms in the memory care unit.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	70-A Based on record review and staff interview, 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 completed at 7:44 AM on 6/17/2021, indicated that staff suspected that resident 1 had drank shampoo that morning. As a result, Poison Control was contacted for guidance. 2. Interview with staff 2 confirmed that the progress notes are accurate, and staff 2 stated that resident 1 suffered no side effects from the suspected ingestion of shampoo. 3. Neither staff 1, staff 2, nor the licensing inspector (LI) were able to locate a facility reported incident report that was completed as a result of this incident.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem Virginia regarding the Statement of Deficiencies date 01/21/2022 but received 02/07/2022. 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 regulatory requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Unable to retroactively correct incident notification. 2. The Executive Director or Designee will provide education for all managers, nurses, and RMAs on reporting of any major incident within 24 hours of incident in accordance with the Virginia regulation 22VAC40-73-70-A.
Standard #:	22VAC40-73-680-B
Complaint related:	Yes
Description:	680-B Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. During a tour of the facility?s safe secure unit on 01/21/2022 at approximately 12:44 PM, collateral 1 observed 10 unlabeled unopened chocolate Ensure Original supplemental drinks inside of an unlocked refrigerator which was located in the corridor outside of room 16 that was accessible to all residents. 2. During a tour of the facility?s safe, secure unit on 01/21/2022, collateral 1 observed, at approximately 12:45 PM, a small, white round pill labeled with ?337? on the floor in front of the closet in resident 4 room.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem Virginia regarding the Statement of Deficiencies date 01/21/2022 but received 02/07/2022. 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 regulatory requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Health and Wellness Director or Designee will provide medication management education for all current LPNs and RMAs completed by March 31, 2022. 2. The Executive Director, Maintenance Director, Health and Wellness Director, or Designee will provide move-out process education for all current staff by March 31, 2022. 3. The Health and Wellness Director or Designee will conduct medication audit for all current medications to be completed no later than March 31, 2022. 4. To assist with on-going compliance, the Health and Wellness Director will randomly complete medication cart audits on all medication carts once a month for three months.