VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Danville Piedmont
149 Executive Court
Danville, VA 24541
(434) 799-1930

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: April 25, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

The LI for Brookdale Danville Piedmont conducted a monitoring visit at the facility on 04/25/2022 in conjunction with another LI from 9:00am until 2:00pm and noted 48 residents to be in care. A tour of the facility physical plant was conducted and required posting were noted. The morning exercise activity and mid day meal were observed. The 11:00am medication pass was observed and the medication carts were audited. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. An exit interview was conducted with the facility Administrator on the day of inspection in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on an audit of the facility medication carts, the facility failed to ensure that blood glucose monitoring practices that are consistent with CDC recommendations were followed. EVIDENCE: 1. The Mount Cross medication cart contained a glucometer bag labeled for resident 10 on the cart but the meter inside the bag was not labeled with the residents name. 2. The T-Bird medication cart contained glucometer bags labeled for residents 11 and 12 on the cart but the meters inside of the bags were not labeled with the residents name. 3. The T-Bird medication cart contained a glucometer bag labeled for resident 5 on the cart but the meter inside of the bag was labeled for resident 12.
Plan of Correction:	The following is Brookdale Danville Piedmont, formerly known as Abingdon Place of Danville, Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated April 25, 2022. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. ? Glucometer meters will be labeled with the resident name ? HWD/Designee will audit carts to verify all glucometer meters are labeled with the residents name ? To assist with compliance, the HWD/designee will audit carts weekly for 4 weeks to verify compliance
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that the results of a risk assessment documenting the absence of tuberculosis was submitted for each staff person on or within seven days prior to the first day of work at the facility. EVIDENCE: 1. The record for staff person 3, hired 03/21/2022, contained a TB screening chest x-ray report with a completion date of 02/04/2021.
Plan of Correction:	? Staff will be administered TB or have a TB screening to assess for risk of tuberculosis within seven days prior to the first day of work at the facility. ? BOC/designee will assist with compliance of TB screenings prior to first day of work at the facility. ? To assist with ongoing compliance/Executive Director (ED)/designee will audit new hires monthly for three (2) months to verify all associates are screened for TB within 7 days of starting at the facility
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure that physical examinations were completed within 30 days preceding admission and contained all required information. EVIDENCE: 1. The record for resident 6, admitted on 02/08/2022, has documentation on the physical examination that the actual exam was conducted on 08/05/2021. The physical examination form was also incomplete as it did not contain information as to whether the resident was ambulatory or non-ambulatory.
Plan of Correction:	? ED/designee will re-educate HWD/Resident Care Coordinator/RMAs on documentation requirements regarding physical examination being conducted within 30 days of move in as well as ambulatory status must be noted on the physician?s plan of care. ? To assist with compliance, weekly for four (4) weeks, the ED/HWD/Designee to review new admissions for completeness of the physicians plan of care.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of resident records, the facility failed to ensure that individualized service plans (ISP) were signed by the resident or their legal representative. EVIDENCE: 1. The record for resident 3 has documentation that the residents ISP was updated on 12/07/2021 but the ISP has not been signed by the resident or their legal representative.
Plan of Correction:	? HWD/Designee will review ISP?s to verify signature by the resident or legal representative or document attempts to get the signature ? To assist with compliance HWD/Designee will review ISP?s for signatures weekly times 4 weeks.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to ensure that individualized service plans (ISP) were updated to reflect changes in a residents condition. EVIDENCE: 1. The record for resident 1 has documentation that the resident is receiving wound care services to the right heel from a Home Health Agency. The wound care and Home Health services are not documented on the residents ISP dated 01/24/2022.
Plan of Correction:	? HWD/Designee will review ISP?s to verify that all individualized services being received are noted on the ISP ? To assist with compliance the HWD/Designee will audit ISP?s to verify weekly times 4 weeks.
Standard #:	22VAC40-73-640-A
Description:	Based on a review of facility documentation, the facility failed to follow their procedures for methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The shift change sign sheet for counting controlled substances on the Mount Cross medication cart did not have staff signatures for the count at 3pm on 04/06/2022 and 11pm on 04/06/2022. 2. The shift change sign sheet for counting controlled substances on the T-Bird medication cart did not have staff signatures for the count at 11pm on 04/02/2022 and 11pm on 04/16/2022.
Plan of Correction:	? HWD/ED/Designee will review accurate counts of controlled substance count sheets when medication administration staff changes. ? To assist with compliance the HWD/ED/Designee will review controlled substance count sheets weekly times 4 weeks.
Standard #:	22VAC40-73-700-2
Description:	Based on observations of the facility physical plant, the facility failed to ensure ?No Smoking-Oxygen in Use? signs were posted in any room where oxygen is in use. EVIDENCE: 1. Room 13, which belonged to resident 2, contained eight containers of oxygen; however, a ?No Smoking-Oxygen in Use? sign was not posted in the room on the day of inspection.
Plan of Correction:	? HWD/Designee will verify that all residents with oxygen have the no smoking oxygen in use signs on doors. ? HWD/Designee will audit all residents on oxygen rooms to verify signage is in place weekly times 4 weeks.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior on good repair. EVIDENCE: 1. The second set of columns inside from the front door of the facility were noted to have cracked drywall around the columns at the ceiling.
Plan of Correction:	? Maintenance Director/ED/designee will have the columns inside of the front door of facility checked for safety and repair damaged drywall around the ceiling. ? Maintenance Director will inspect building routinely for damages weekly time 4 weeks.