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:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-1180-B
Description:	Based on observation and staff interviewed, the facility failed to ensure on the safe, secure unit, 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. On 5-31-22 during a tour of the facility with staff #4, eleven screws and metal brackets were observed in the window in room #15. 2. On 6-2-22, a vase filled with various chains was observed on the dresser in room #15. 3. Staff #1 and #2 acknowledged these items may be harmful to the residents on the safe, secure unit.
Plan of Correction:	? The Executive Director and Maintenance Director immediately removed vase with chains and secured maintenance supplies from apartment 15. ? The Executive Director, Maintenance Director or Designee will provide education for all current associates on environmental precautions and providing a safe, secure environment for residents no later than 7/1/2022. ? The Executive Director, Health and Wellness Director, Managers or Designee will complete a full sweep of memory care unit daily for two weeks to assist with environmental precautions and secure any items found by 7/1/2022. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct random room sweeps weekly in the memory care unit for 2 months.
Standard #:	22VAC40-73-320-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the resident?s admitting physical examination was completed within 30 days preceding admission and included all of the required information for a resident. Evidence: 1. On 5-31-22, resident #3?s physical examination in the record was signed and dated 11-19-21. The resident?s date of admission was documented as 1-4-22. The physical also did not include the resident?s height. 2. Staff #2 acknowledged the aforementioned resident?s physical was not in compliance with the regulation for admissions.
Plan of Correction:	? Unable to retroactively correct Physical Examination and report date upon admission for resident number 3. ? Executive Director to provide education for the Sales Manager and Resident Care Coordinator regarding resident Physician physicals completed 30 days or less prior to admission to assisted living community by 7/1/2022. ? The District clinical team, Executive Director, Health and Wellness Director or Designee will conduct audits of all current resident physical examination and report for compliance by 7/1/2022. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct review of all new resident physical examination dates at admission date for 2 months.
Standard #:	22VAC40-73-380-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social data form included all required information and was kept current for four of six record reviewed. Evidence: 1. On 5-31-22, resident #1?s personal and social data form was missing the resident?s date of admission. 2. Resident #3?s personal and social data form was missing the resident?s date of admission, physician?s information, dentist information and resident?s interest/hobbies. 3. Resident #4?s personal and social data form was missing resident?s date of admission and Gabapentin and Doxylamine allergy. 4. On 6-2-22, the facility?s ?Emergency fact sheet? documented the resident #5?s allergies were pollen and environmental. This information was not documented in the allergy section of the personal and social data form. The resident?s social data form documented the resident?s military service was Navy. A copy of the resident?s military card in the record noted the resident was Army. 5. Staff #1 and #2 acknowledged the resident?s personal and social data form did not include all required information.
Plan of Correction:	? The Executive Director, Resident Care Coordinator, Business Office Manager or Designee will ascertain resident personal and social data for resident number 1, 3, 4 and 5 no later than 7/1/2022. ? The Executive Director or designee will provide education for the Sales Manager, Resident Care Coordinator and Business Office Manager on resident personal and social data prior to or at date of admission and Virginia regulations to be completed by 7/1/2022. ? The District clinical team, Executive Director or Designee will audit of all current resident records for resident personal and social data to be completed and corrected by 7/1/2022. ? To assist with ongoing compliance, the Executive Director, Health and Wellness Director or Designee will audit all new admission resident record for resident personal and social data and compliance once a month for two months.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six of six records reviewed. Evidence: 1. On 5-31-22, resident #1 was observed with glasses. The uniformed assessment instrument (UAI) dated 5-3-22 documented walking and stairclimbing not performed. These needs were not documented on the resident?s individualized service plan (ISP) dated 5-4-22. Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six of six records reviewed. Evidence: 1. On 5-31-22, resident #1 was observed with glasses. The uniformed assessment instrument (UAI) dated 5-3-22 documented walking and stairclimbing not performed. These needs were not documented on the resident?s individualized service plan (ISP) dated 5-4-22. 2. Resident #2?s uniformed assessment instrument (UAI) dated 4-1-22 documented wheeling and stairclimbing need as not performed. The ISP dated 4-1-22 did not include these assessed needs. 3. Resident #3?s glasses was not documented on the ISP dated 1-4-22. 4. Resident 4?s record included a signed order dated 5-20-22 for oxygen 2 Liter via nasal cannula. This was not documented on the resident?s ISP dated 4-7-22. 5. On 6-2-22, resident #5?s allergy documented on the facility?s ?Emergency fact sheet? did not include resident?s allergy to pollen and environmental allergies. Resident?s uniformed assessment instrument (UAI) dated 4-6-22 documented bathing assessed as mechanical help/supervision. The ISP dated 4-6-22 did not document what mechanical help was needed to assist the resident. Walking need assessed as mechanical help only, the ISP documented resident required the use of the walker and staff supervision. Stairclimbing assessed as mechanical help/ physical assistance, the ISP documented use of handrail and supervision. 6. Resident #6?s UAI dated 6-1-22 documented bathing need as mechanical help/physical assistance. The ISP dated 4-7-22 did not document what mechanical help was needed to assist the resident. 7. Staff #1 and #2 acknowledged the aforementioned residents? ISP did not include all assessed needs.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/13/22. 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 improvements to satisfy that objective. 22VAC40-73-450-C Individualized Service Plans ? The District clinical team, Executive Director or Designee will update resident number 1, 2, 3, 4, 5 and 6 ISP and UAI to reflect current resident needs by 7/1/2022. ? The Executive Director or Designee will provide education for current UAI/ISP certified LPN(s) on updating ISP as changes occurs by 7/1/2022. ? The District clinical team, Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for current care needs by 7/01/2022. ? To assist with ongoing compliance, The Executive Director, Health & Wellness Director or Designee will conduct Individualized Service Plan audits monthly on 3 resident for two (2) months.
Standard #:	22VAC40-73-450-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is 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 (ISP) for two of six records reviewed. Evidence: 1. On 5-31-22, resident #4?s record included a hospice plan of care of services from a local agency which included nursing, social worker and certified nurse aid. The hospice services were not documented on the individualized service plan dated 4-7-22. 2. On 6-2-22, resident #6?s ISP documented resident receiving hospice services. Staff #1 contacted agency and received a copy of the resident?s plan of care. A review of the resident?s plan of care received from the agency on 6-2-22 documented resident receiving social work, volunteer and chaplain services. The services provided were not documented on the ISP dated 4-7-22. 3. Staff#1 and #2 acknowledged the aforementioned residents? ISP did not include all hospice services.
Plan of Correction:	? The District clinical team, Executive Director or Designee will update resident number 4 and 6 ISP to reflect current resident hospice plan of care and/or obtain the Hospice written Plan of Care for the residents records by 7/1/2022. ? The Executive Director or Designee will provide education for current UAI/ISP certified LPN(s) on updating the ISP for Hospice plan of care as changes occurs by 7/1/2022. ? The District clinical team, Health & Wellness Director or Designee will audit all current resident that receive Hospice Services and the Individualized Service Plans for current hospice plan of care by 7/01/2022. ? To assist with ongoing compliance, The Executive Director, Health & Wellness Director or Designee will conduct random Individualized Service Plan audits for residents receiving Hospice Services monthly for two (2) months.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was updated as needed for a significant change of a resident?s condition for three of six records reviewed. Evidence: 1. On 5-31-22, resident #1?s record included documentation of physical therapy (PT), occupational therapy (OT) and speech therapy (ST) services. On 6-2-22, staff #1 contacted the home-health agency and received the resident?s plan of care. Documents received noted OT last saw resident on 4-25-22, PT last seen on 3-30-22; ST last seen on 3-18-22 and skilled nursing (SN) last seen on 4-25-22. These services were not documented on the resident?s ISP dated 5-4-22. The resident?s date of admission documented as 4-26-22. 2. Resident #3?s record documented on 1-19-22, physical therapy (PT) to evaluate and treat. Notes in the record dated 1-27-22 noted 3rd visit, 1-31-22 noted 4th visit and 2-1-22 noted 5th visit. Occupational therapy (OT) to evaluate and treat dated 1-19-22. Notes in the record dated 1-20-22 noted beginning of services, 1-31-22 noted 4th visit, 2-2-22 noted 5th visit, and and 2-7-22 noted discharge from services. Speech therapy (ST) to evaluate and treat dated 3-10-22. ST notes were dated on 1-20-22, 1-24-22 noted 2nd visit, 1-26-22 noted 3rd visit and 1-3-22 noted 4th visit. The resident?s ISP dated 1-4-22 did not include these services since admission on 1-4-22. 3. On 6-2-22, resident #5?s record included recommendation for physical therapy, occupational therapy and skilled nursing on the admitting physical examination dated 3-29-22. Staff #1 contacted the home-health agency and the resident?s plan of care was provided. The plan of care received on 6-2-22 documented physical and occupational therapy services evaluation requested date was 4-21-22. The document also noted resident received 6 visits from physical therapy and 5 visits from occupational therapy. The resident?s ISP dated 4-6-22 did not include home-health services since admission on 4-6-22. 4. Staff #1 and #2 acknowledged the aforementioned residents? ISP was not updated to reflect resident?s change in condition.
Plan of Correction:	? The District clinical team, Executive Director or Designee will update resident number 1, 3 and 5 ISP to reflect current resident care needs by 7/1/2022. ? The Executive Director or Designee will provide education for current UAI/ISP certified LPN(s) on updating the ISP as changes occurs to reflect current care needs by 7/1/2022. ? The District clinical team, Health & Wellness Director or Designee will audit all current resident Individualized Service Plans for current care needs and make needed updates by 7/01/2022. ? To assist with ongoing compliance, The Executive Director, Health & Wellness Director or Designee will conduct random Individualized Service Plan audits for residents current care needs monthly for two (2) months.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to the residents. Evidence: 1. On 5-31-22, at 10:35 a.m. staff #6 was observed posting the current menu for the week and the daily menu. The daily breakfast menu for the day, 5-31-22 was posted following the breakfast meal being served. 2. Staff #6 acknowledged the current weekly menu was not posted as required.
Plan of Correction:	? The Executive Director and Dining Manager immediately corrected posting of current menus and snacks at time of inspection. ? The Executive Director or Designee will provide education for the Dining Manager on posting current weekly menus and snacks in a conspicuous location for the residents by 7/1/2022. ? To assist with ongoing compliance, The Executive Director, Dining Service Manager or Designee will conduct random Menu and Snacks schedule postings weekly for two (2) months.
Standard #:	22VAC40-73-680-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. On 5-27-22, the inspector received an incident report for a medication error for resident #7. On 6-2-22, the record included a note of a request from the resident?s spouse for lab-work, spouse suspected resident may have a UTI. The record included an order to ?obtain UA and Urine Culture for possible UTI start date of 3-30-22?. 2. On 4-6-22 a prescriber?s order was provided to the facility. The order was for Bactrim DS 800 mg-160 mg oral tablet; Take 1 tab(s) orally every 12 hours for 7 day(s). Start date: 4-6-2022, End date: 4-12-22. 3. The April 2022 medication administration record (MAR) documented Bactrim DS tablet to be administered 1 tablet by mouth every 12 hours every 7 day(s). The MAR for April 2022 and May 2022 documented the resident received the antibiotic twice a day on Thursday of each week, beginning 4-7-22 and continued until the error was discovered in May. 4. Staff #1 acknowledged the aforementioned resident?s antibiotic was not administered per the prescriber?s instructions.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 6/13/22. 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 improvements to satisfy that objective. ? The Executive Director, Health and Wellness Director or Designee will audit Physician orders to Admiration Record for resident number 7 and make updates as needed by 7/1/2022. ? The Executive Director, Health & Wellness Director or Designee will provide education on administration of medication and administration in accordance with physician?s orders for current LPN?S and RMA?s no later than 7/1/2022. ? The District Clinical Team, Executive Director, Health & Wellness Director or Designee will complete an audit of all current residents? current active physician orders to medication administration record to assist with medications administrated as ordered by 7/1/2022. ? 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 week for three (3) months.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 6-2-22 during a medication cart check with staff #3, resident #2?s PRN Tylenol was not available on the cart. A check was made of the medications in the nursing station, but the resident?s Tylenol was not available. A check of the April 2022 medication administration determined the medication was also not available in April 2022. 2. Staff #3 acknowledged the aforementioned resident?s PRN Tylenol was not available on the cart on 6-2-22.
Plan of Correction:	? The Executive Director, Health and Wellness Director or Designee will audit physician orders to medication available for resident number 3 and will coordinate with pharmacy that all prn medications are present and available by 7/31/2022. ? The Executive Director, Health & Wellness Director or Designee will provide education on administration of medication and administration in accordance with physician?s orders and availability of prn medications for current LPN?S and RMA?s no later than 7/31/2022. ? The District Clinical Team, Executive Director, Health & Wellness Director or Designee will complete an audit of all current residents? physician orders to medication availability and coordinate with pharmacy to have all medications routine and prn available for the resident by 7/1/2022. ? To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will audit all current resident physician?s orders and medication availability once a week for two (2) months.
Standard #:	22VAC40-73-680-N
Description:	Based on staff interviewed, the facility failed to ensure stat-drug may only be used when the drug is removed from the stat-drug box and administered by a nurse, pharmacist, or prescriber licensed to administer medications. Registered medication aides are not permitted to either remove or administer medications from the stat-drug box. Evidence: 1. On 5-31-22 during the medication pass observation with staff #3, resident #2?s Furosemide was not available in the facility to administer the 09:00 a.m. dosage as prescribed. 2. Later staff #3 during the afternoon, the inspector was informed the resident was given the medication from the facility?s stat-drug box. According to staff #3, Registered Medication Aide (RMA) and verified by staff #9 (agency nurse) resident # 3 received the Furosemide from the facility?s stat-box. According to staff #3 and staff #9, staff #9 gave staff #3 the Furosemide medication to administer to the resident. 3. During conversation with staff #9, staff stated it was okay for staff #3 to give the medication because staff #9 pulled it from the facility?s stat-drug box. 4. On 5-31-22 staff #3 and #9 acknowledged staff #3?s administration of medication from the facility?s stat-box as directed to do so by staff #9 was not in accordance with the Assisted Living Regulations.
Plan of Correction:	? The Licensing Inspector provided clarification of Virginia regulation 22VAC40-73-680-N for District Director of Clinical Services, District Director of Operations, Interim Executive Director and Area Nurse Manager at time of Inspection. Immediate correction made on 5/31/2022. ? The Executive Director, Health & Wellness Director or Designee will provide education on the use of and regulations regarding Stat-drug boxes in Virginia for all current LPN?S and RMA?s no later than 7/1/2022. ? To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will provide on-going education for current LPN?s and RMA?s on the use of Stat-drug boxes in Virginia monthly for two (2) months.