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: Feb. 18, 2022 , Feb. 23, 2022 , March 11, 2022 and March 14, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

An unannounced complaint inspection was conducted on 2-14-22 regarding a complaint that came to the regional licensing office alleging resident's care and medications were not be taken care of in the facility, resident had wounds on sacral area. Interviews and records reviews were conducted and determine the allegation to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days: 3-26-22.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record reviewed and record reviewed, the facility failed to ensure it report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 2-18-22, the inspector requested a list of residents with wounds in the facility. Residents #1, #2 and #3?s records were reviewed and wound care services were noted. 2. Resident #1?s Progress notes documented resident returning from the emergency room on 1-11-22 with ?Allevyn on buttocks for pressure ulcer?. On 1-12-22, progress notes documented a local home health agency contacted to address skin care evaluation. On 1-20-22 the skilled nurse from a home-health agency documented a sacral/coccyx wound, .8 X .3 X .1. 3. Resident #2?s Hospice progress notes documented ?mild redness to sacral area on 9-21-2; 0.5 X 0.5 cm opened to sacrum on 10-22-21; wound scrubbed, collagen powder placed in wound bed w/solosite & covered w/ calcium alginate and covered with sterile dressing noted on 11-29-21; pt w/3 X 4 cm, 4cm depth stage 4 wound w/eschar & odor, order for Flagyl & Cipro. 4. Resident #3?s record documented ?skilled nursing providing wound care services to left upper extremities and right upper extremities & right face skin tears. 5. Staff #1 acknowledged stage 4 wound was not reported to the regional licensing office.
Plan of Correction:	? Unable to retroactively correct date of notification. Resident number 2 no longer in community. ? The Executive Director will provide education for the Health & Wellness Director, Resident Care Coordinator and current nurses on timely and accurate incident reporting by 5/09/2022. ? To assist with ongoing compliance, The Health and Wellness Director or Designee will report timely and accurately any major incident that has negatively affected or that threatens the life, health, safety, or welfare of current residents
Standard #:	22VAC40-73-440-K
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) was in compliance with 22VAC30-110 for one of three residents. Evidence: 1. Resident # 2's uniformed assessment instrument (UAI) dated 10-15-21 was completed by a staff member, but the second signature was not completed by the administrator or designee. 2. Staff #1 and 3 acknowledged the UAI was not signed by the designee or administrator as required.
Plan of Correction:	? Unable to retroactively correct discharged resident?s initial Uniform Assessment Instrument. Resident number 2 no longer in community. ? The Executive Director or Designee will provide education to Health & Wellness Director and Resident Care Coordinator for Uniform Assessment Instrument required signatures by 5/09/2022. ? To assist with ongoing compliance, The Health & Wellness Director or Designee will audit all current resident Uniform Assessment Instrument for required signatures no later than 5/09/2022.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of three residents . Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 4-26-21 documented bathing assessed as physical assistance. The individualized service plan (ISP) with an outcome date of 4-26-22 documented mechanical help and physical assistance. Bowel and bladder need assessed as continent. The ISP documented resident wears protective briefs. Transfer need assessed as no help; however, toileting need documented resident requires supervision for safe transfer. Stairclimbing assessed as not performed. The ISP did not document how service, if need would be performed and who would perform services. Behaviors not documents on UAI; however, ISP documented 11-30-21 date identified, resident assessed with aggressive behavior. 2. Resident #3?s uniformed assessment instrument (UAI) dated 6-8-21 assessed walking need as no help. The ISP dated 6-22-21 documented resident needed a walker. Wheeling and stairclimbing need assessed as not performed. The ISP did not document how and who would provide services. 3. Staff #1 and #2 acknowledged the aforementioned resident?s ISP did not include all assessed needs.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 3/14/2022 and received 3/16/2022. 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 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. ? Unable to retroactively correct Individualized Service Plan. Resident number 2 no longer in community. ? The Individualized Service Plans (ISP) for Resident number 1 and resident number 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 3/30/2022. ? The Executive Director will provide education for the Health and Wellness Director on Individualized Service Plans (ISP) compliance by 5/09/2022. ? The Health and Wellness Director or Designee will audit of all current residents Individualized Service Plans (ISP) for care services provided completed by 5/09/2022.
Standard #:	22VAC40-73-450-D
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when hospice services are provided to a resident the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: 1. Resident #2?s individualized service plan did not include the hospice services being provided by the new hospice agency. The resident changed hospice agency approximately 2-11-22 (date of hospice care- comfort medications order). 2. Staff #1 and #2 acknowledged the resident?s ISP should have been updated to include the change in services and the services provided by the new provider.
Plan of Correction:	? Unable to retroactively correct Individualized Service Plan for resident number 2, as resident number 2 no longer in community. ? The Executive Director or Designee will provide education for the Health and Wellness Director and Health on Individualized Service Plans (ISP) compliance by 5/09/2022. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit random current residents Individualized Service Plans (ISP) for identified hospice services and completion of ISP once a week for 4 weeks.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or his designee who has developed the plan and the resident or his legal representative. Evidence: 1. Resident #1?s individualized service plan (ISP) with the assessed need date of 4-26-21 and expected outcomes dates of 4-26-22 did not include a date the developer completed the plan and no signature and date for the resident and or legal representative. 2. Staff #1 and #3 acknowledged the aforementioned resident?s ISP did not have a dates and signatures as required.
Plan of Correction:	? The Executive Director or Designee will provide education to The Health & Wellness Director on ensuring ISP signature and date of developer and signature and date of legal representative by 5/09/2022. ? The Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for signatures and dates of developer and signatures and dates of legal representative by 5/09/2022. ? To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan audits for signatures and dates of developer and signatures and dates of legal representative of random resident charts once a week for 4 weeks.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: 1. Resident #1?s individualized service plan (ISP) with needs outcome achieved date of 4-26-22 was not updated to include resident?s home-health services for wound of sacral area, Occupational Therapy (OT) services noted in record, last visit (#5) dated 1-19-22. Physical Therapy (PT) services noted in record with a discharged date of 2-4-22. 2. Resident #2?s record did not have a current updated annual review of the ISP. The last ISP in the record is dated 11-19-20 with updated needs with an outcome date of 12-15-21 and 12-22-21. 3. Resident #3?s individualizes service plan was not updated to include home-health services, skilled nursing for wound care services which began on 12-2-22 and documentation of services being received as of 2-18-22. Occupational Therapy services provided beginning 6-12-21 with ?services one time week one and two times week two to maximize safety and independence with adls and functional mobility and decrease impairments limiting function?. Physical Therapy services provided beginning 6-15-21 to include ?strengthening, balance training, gait training and transfer training? per home-health notes. Speech Therapy (ST) services beginning 6-15-21, ?dysphagia assessment due to complaints of food or drink getting stuck in throat?. ST plan of care of services: one time one week, two times week for five weeks and one time for one week. The resident?s ISP dated 6-8-21 did not include these home-health services 4. Staff #1 and #2 acknowledged the aforementioned residents? ISPs was not updated to include changes in condition.
Plan of Correction:	? Unable to retroactively correct resident number 2 Individualized Service Plan as resident number 2 no longer in community. ? The Executive Director or Designee will provide education for the Health and Wellness Director on updating Individualized Service Plans as changes occur by 5/09/2022. ? To assist with ongoing compliance, The Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for updates needed by 5/09/2022.
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident?s record. Evidence: 1. Resident #3?s progress notes dated 12-6-21 documented resident returned to facility from emergency room following an unwitnessed fall with a ?hand brace on right wrist?. Progress noted dated 12-9-21 documented resident to follow-up with orthopedic for wrist. Physician?s order dated 12-8-21 documented resident is to wear left brace at all times. The record did not have documentation of the orthopedic visit and documentation of the resident wearing the brace. Staff #2 stated the resident refused to wear brace, there was no documentation in the record of refusal. 2. Staff #1, #2 and 3 acknowledged the aforementioned resident?s record did not have documentation of resident wearing brace to left wrist and no documentation of resident?s representative taking resident for orthopedic visit.
Plan of Correction:	? The Health & Wellness Director or Designee will provide education on administration of treatments ordered by a physician according to his instructions for current RMAs and LPNs by 5/09/2022. ? The Health & Wellness Director or designee will review the physician?s treatment orders for three residents no later than 5/09/2022. ? To assist with ongoing compliance, the Health & Wellness Director or Designee will audit all current resident new physician?s treatment orders and once a week for four weeks.