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: April 6, 2022

Complaint Related: No

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 BUILDING AND GROUNDS 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

320-A, 380-A

Comments:

The LI for Brookdale Salem, along with an additional LI, conducted an unannounced renewal study on 04/06/2022 from 08:45 AM until 04:00 PM, finding 63 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, a review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and craft activity. Eight resident records were thoroughly reviewed, and an additional six were partially reviewed in relation to the observation of the medication pass, special diets, or other services received. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of four staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator and the Health and Wellness Director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-50-B
Description:	50-B Based on record review, the facility failed to ensure that written acknowledgment of the receipt of disclosure by the resident or his legal representative shall be retained in the resident?s record. EVIDENCE: 1. The record for resident 1, admitted 01/29/2022, did not contain written acknowledgment of the receipt of the facility?s disclosure statement by resident 1 or his legal representative. 2. Interview with staff 5 indicated that there is no written acknowledgment of the receipt of disclosure by resident 1 or his legal representative.
Plan of Correction:	? Unable to retroactively correct date of Written Disclosure for resident number one. Written Disclosure to be updated in resident number one medical records by 4/30/22. ? The Executive Director will provide education for the Sales Manager, Business Office Manager or designee on the regulations and completion of the Written Disclosure per state regulation by 4/30/22. ? To assist with on-going compliance; the Executive Director or Designee will audit 10% of resident records for Written Disclosure once a month for 3 months.
Standard #:	22VAC40-73-310-B
Description:	310-B Based on record review, the facility failed to ensure that prior to admission, an interview was documented between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any, to make the determination that the facility can meet the needs of the individual. EVIDENCE: 1. The record for resident 1, admitted 01/29/2022, did not contain documentation that a determination interview had occurred between the facility and resident 1 prior to admission. 2. Interview with staff 5 indicated that there is no documentation of the interview.
Plan of Correction:	? Unable to retroactively correct date of Administrator Interview for resident number one. Administrator Interview documented to be updated in resident number one medical records by 4/20/22. ? The District Director of Operations or Designee will provide education for the Executive Director on the regulations and completion of the Criminal Back Ground Check within 30 days of start date of employment by 4/30/22. ? To assist with on-going compliance; the Business Office Manager or Designee will implement a new hire checklist to verify the Criminal Back Ground Check is completed within required timeframe by 4/30/2022.
Standard #:	22VAC40-73-560-F
Description:	560-F Based on observation of one of the facility?s medication carts, the facility failed to ensure all records were treated confidentially and that information is made available only when needed for care of the residents. EVIDENCE: The second floor medication cart narcotic binder was observed multiple times by collateral 1 laying unattended on top of the second floor medication cart during the on-site renewal inspection on 04/06/2022. The book contained names of multiple second floor residents along with documentation regarding which narcotics those residents are prescribed.
Plan of Correction:	? The Executive Director, Health and Wellness Director or Designee will provide education for current nurses and RMAs on resident health records and record confidentiality completed no later than April 21, 2022. ? The Executive Director, Health and Wellness Director or Designee will update the medication cart audit tool to reflect confidentiality of Narcotic Log Book no later than April 21, 2022. ? To assist with on-going compliance; the Executive Director, Health and Wellness Director or Designee will conduct visual inspection of narcotic log book daily for 4 weeks and then weekly for 1 month to ensure narcotic log book is secured.
Standard #:	22VAC40-73-640-A
Description:	640-A Based on document review and observation, the facility failed to implement its medication management plan (MMP), specifically regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, and methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. Regarding maintenance of scheduled II ? V medications, the facility?s MMP, dated 10/2018, states that these medications ?Will be counted by a licensed nurse/RMA from the off going shift and one from the oncoming shift. This procedure will occur at the beginning of each shift or whenever a change is made within that shift. Both staff?s signature and the count of bingo cards and sheets will be documented on either the Schedule II count sheet provided by the communities preferred pharmacy and the communities controlled Medication Inventory sheet?. 2. While performing an audit of the facility?s medication cart for the memory care unit at approximately 12:26 PM on the date of inspection, LI observed that the narcotic count log for the memory care unit was not completed on the following dates and shifts: On 04/01/2022, the log was not signed by the off-going staff member on the 3 PM ? 11 PM shift; On 04/03/2022, the log was not signed by the on-coming staff member on the 11 PM ? 7 AM shift and not signed by the off-going staff member on the 7 AM ? 3 PM shift; On 04/06/2022, the log was signed in advance by the off-going staff member for the 3 ? 11 PM shift. 3. The facility?s current medication management plan indicated the following: ?A medication cart audit occurs quarterly and is completed by the HWD/RCC or their designee. An audit requires removal and reorder of all expired medications. The HWC and RDD will review the forms after the audit has been completed.? 4. During the inspection, the document ?Daily Med Cart Checks? was provided. This form contained documentation that an audit of both of the facility?s medication carts was completed by staff on 04/03/2022. The form also includes a component for checking for expired medications. 5. The record for resident 12 contained a physician?s order, dated 04/01/2022, for Prevident 5000 Booster Plus paste, for one dental application at bedtime for oral hygiene. 6. During the audit of the facility?s second floor medication cart, collateral 1 noted that the two containers of this paste for the resident contained an expiration date of 02/2022. This was also observed by staff 5 and 6.
Plan of Correction:	? The Executive Director, Health and Wellness Director or Designee will complete Medication Cart Audit on the community?s three-medication carts by 04/21/2022. ? The Executive Director, Health and Wellness Director or Designee will provide education for current nurses and RMAs on reviewing medications received from pharmacy for expiration dates when receiving medications from pharmacy to be completed by 04/29/2022. ? To assist with on-going compliance; the Executive Director, Health and Wellness Director or Designee will conduct medication cart audits weekly on all three carts x2 months.
Standard #:	22VAC40-73-680-B
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: During a tour of the facility?s safe, secure unit on the date of inspection at approximately 9:01AM, collateral 1 and staff 5 observed a small, white pill on the bedside table in resident 9?s room.
Plan of Correction:	? Immediate removal of medication. ? The Executive Director, Health and Wellness Director or Designee will provide education for all current Nurses and RMAs completed no later than 04/21/2022 on medication passes including the medication management plan. ? To assist with on-going compliance; the Executive Director, Health and Wellness Director or Designee will observe one medication pass weekly for 8 weeks.
Standard #:	22VAC40-73-870-A
Description:	870-A Based on observation, the facility failed to ensure that the interior of the building was maintained in good repair. EVIDENCE: During a tour of the physical plant of the facility on the date of inspection, collateral 1 noted that the carpet resident 10?s room contained multiple stains. Also, the LI observed a dark colored stain on the carpet beside the television stand in resident 11?s room.
Plan of Correction:	? The Executive Director, Maintenance Manager or Designee will clean resident number 10 and resident number 11 apartment carpet no later than 4/30/2022. ? The Executive Director or designee will provide education for Maintenance Manager and Maintenance Technician on maintenance of interior and exterior to be kept in good repair and kept clean and free of rubbish to be completed by 5/15/2022. ? The Maintenance Manager or Designee will conduct visual inspection of current resident apartment carpets in memory care completed by 5/15/2022. ? To assist with ongoing compliance, the Maintenance Manager or Designee will conduct visual inspection of random apartment carpets, community common areas and hallway carpets once a month for three months.
Standard #:	22VAC40-73-870-E
Description:	870-E Based on observation, the facility failed to ensure that all fixtures and equipment, including sinks, were kept clean and in good repair and condition. EVIDENCE: 1. During a tour of the physical plant of the facility on the date of inspection at approximately 09:40 AM, collateral 1 noted that the faucet of the bathroom sink in resident 11?s room contained a black substance around the hot water handle and collateral 1 noted it was difficult to turn the hot water off and on. In addition, the water continued to drip after the hot water was turned off by collateral 1. 2. Resident 11 stated that she has also had an issue with the faucet.
Plan of Correction:	? The Executive Director, Maintenance Manager or Designee will clean resident number 11 apartment sink and replace sink faucet no later than 4/30/2022. ? The Executive Director or designee will provide education for Maintenance Manager and Maintenance Technician on maintenance of interior and exterior to be kept in good repair and kept clean and free of rubbish to be completed by 5/15/2022. ? The Maintenance Manager or Designee will conduct visual inspection of current residents apartment bathroom sinks in memory care for cleanliness and working condition completed by 5/15/2022. ? To assist with ongoing compliance, the Maintenance Manager or Designee will conduct visual inspection of random apartment bathrooms for cleanliness and in working condition once a month for three months.
Standard #:	22VAC40-90-30-B
Description:	22VAC40-90-30-B Based on staff record review, the facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment. EVIDENCE: 1. The record for staff 7, date of hire 08/25/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 09/01/2021. 2. The record for staff 8, date of hire 09/15/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 09/16/2021.
Plan of Correction:	? Unable to retroactively correct new hire Sworn Statement or Affirmation date. ? The Executive Director or Designee will provide education for the Business Office Manager on the regulations and completion of the sworn statement or affirmation at the time of application and hire by 4/30/22. ? The Business Office Manager or Designee will implement a new hire checklist to verify the sworn statement or affirmation is complete by 4/30/2022 ? To assist with on-going compliance, the Executive director or designee will randomly audit new hire paperwork to verify completion of the sworn statement or affirmation at the time of application and hire once a week for 2 months.
Standard #:	22VAC40-90-40-B
Description:	22VAC40-90-40-B Based on staff record review, the facility failed to ensure that a criminal record history report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff 4, date of hire 07/27/2021, contained documentation that a criminal record history report was not obtained for staff 4 until 04/04/2022. 2. The record for staff 9, date of hire 09/07/2021, contained documentation that a criminal record history report was not obtained for staff 9 until 04/04/2022. 3. Interview with staff 5 confirmed this was accurate.
Plan of Correction:	? Unable to retroactively correct new hire Criminal Back Ground Check date. ? The Executive Director or Designee will provide education for the Business Office Manager on the regulations and completion of the Criminal Back Ground Check within 30 days of start date of employment by 4/30/22. ? The Business Office Manager or Designee will implement a new hire checklist to verify the Criminal Back Ground Check is completed within required timeframe by 4/30/2022 ? To assist with on-going compliance, the Executive director or designee will randomly audit new hire paperwork to verify completion of the Criminal Back Ground Check upon hire once a week for 2 months.