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: Aug. 23, 2022 , Aug. 29, 2022 and Sept. 2, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection was conducted by two licensing inspectors (ERO/PLO) on 8-23-22. (Ar 07:39/ dep 5:20 p.m.) The facility census was 28. A tour of the facility was conducted, a medication pass observation conducted, breakfast meal was observed, water temperature take, call bell not checked due to it be inoperable on the day of the inspection. Staff records and interviews and resident records were reviewed. An exit was conducted on 8-23-22 with the administrator and health and wellness director. The Acknowledgement form was signed and a request for additional documents was asked to be sent to the inspector. The second preliminary exit meeting was conducted virtually on 8-29-22 with the administrator and regional staffs. The final exit meeting was conducted virtually on 9-2-22 with the administrator. The final meeting will be scheduled. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the first aid/Cardiopulmonary resuscitation (CPR) listing posited was kept up to date. Evidence: 1. On 8-23-22, during a tour of the facility with staff #1, the posted first/CPR listing listed staff #10?s first aid date as 6-12-22. Staff #11 and #12, direct care staff members, did not have a date for first aid. According to staff #1, staff would be scheduled for training. 2. On 8-23-22, staff #1 acknowledged the posted first aid/CPR listing was not current/updated as required.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 9/2/22. 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. 22VAC40-73-260-C First aid and CPR certification Date to be corrected: 10/12/22 Staff #12 is no longer an employee. Staff #10 & Staff #11 CPR/First Aid certification will be updated by October 12, 2022. Executive Director will train Business Office Manager on upkeep of First Aid & CPR. To assist with ongoing compliance Business Office Manager/Designee will complete an audit of CPR/First Aid certification of all staff quarterly for one year. Executive Director will do random audits every quarter.
Standard #:	22VAC40-73-325-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. On 8-23-22, resident #4?s individualized service plan (ISP) dated 1-26-22 documented the resident experienced a fall on 3-21-22 and 4-14-22. There was no evidence of a Fall Risk assessment being completed after the falls occurred on 3-31-22 and 4-14-22. 2. On 8-29-22, staff acknowledged the fall risk rating was not completed following resident?s falls.
Plan of Correction:	22VAC40-73-325-B Fall risk rating Date to be corrected: 10/12/22 Executive Director will provide training to the Health & Wellness Director & Health and Wellness Coordinator Fall risk rating process. The Health & Wellness Director, Health & Wellness Coordinator and/Designee will update all residents fall risk ratings. To assist with ongoing compliance, the Executive Director and/Designee will complete an audit to verify the fall risk ratings are updated on three (3) randomly selected residents monthly for two (2) months.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social data information required was kept current for four of six residents? record. Evidence: 1. On 8-23-22, resident #1?s individualized service plan (ISP) dated 11-8-21, August 2022 medication administration record (MAR) and psychiatric progress notes dated 8-10-22 documented resident allergy to Keflex and Ephedrine. The personal and social data form did not document allergy information. 2. On 8-23-22, resident #2?s ISP dated 11-5-21 and August 2022 MAR documented allergy to Ibuprofen and Tramadol. The psychiatric progress notes dated 7-6-22 documented allergy to Donepezil, Ibuprofen and Tramadol. The personal and social data form did not document allergy information. 3. On 8-23-22, resident #3?s August 2022 MAR documented allergy to Clindamycin, Codeine, Erythromycin, Penicillin, Prednisone, Xifaxan and Narcotics. The personal and social data form did not document allergy information. 4. On 8-23-22, resident #4?s August 2022 MAR documented allergy to Aricept. The personal and social data form did not document allergy information. 5. On 8-29-22, staff #1 acknowledged the resident?s personal and social data form was not updated to include all required information.
Plan of Correction:	22VAC40-73-380-B Resident personal and social information Date to be corrected: 10/12/22 Resident #1, resident #2, resident #3 and resident #4 personal and social data form has been updated to reflect their allergies on August 30th. Executive Director, Health & Wellness Director and/or designee will do an audit of all residents personal and social data forms to verify residents? allergies are noted. To assist with ongoing compliance, an audit will be completed on all new residents monthly for two (2) months to verify allergies are noted on their personal and social data forms.
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 8-23-22, resident #1?s uniform assessment instrument (UAI) dated 11-8-21 transferring need assessed as ?no need?. The individualized service plan (ISP) dated 11-8-21 documented mechanical help using the arms of chairs to assist. Stairclimbing need assessed,? human help/supervision and is not performed?. The ISP documented not performed but needs supervision. The UAI documented resident disoriented some spheres all the time, the spheres were not documented. The ISP documented disoriented to time and place, but did not identify how to re-orient resident. The record included psychiatric progress notes for the resident, however, this need was not documented on the individualized service plan (ISP) dated 11-8-21. 2. On 8-23-22, resident #2?s Donepezil allergy noted in psychiatric notes dated 7-6-22 not documented on resident?s ISP dated 11-5-21. Prescriber?s order for mechanical soft diet and serve meal in small sauces/bowl not documented on ISP. UAI dated 11-8-21, toileting need assessed ?human help/physical assistance?. The ISP documented ?mechanical help/physical, use of grab bars and assistance and resident to provide services?. 3. On 8-23-22, resident #3?s UAI dated 5-3-22 documented a need of ?mechanical and human help assistance for walking?. This need was not documented on the ISP dated 5-3-22. 4. On 8-23-22, resident #4?s UAI dated 1-26-22 documented a need of ?mechanical and human help for stairclimbing?. The UAI also documented a need of ?mechanical and human help for stairclimbing?. These need were not documented on the ISP dated 1-26-22. 5. On 8-23-22, resident #5?s UAI dated 7-13-22 documented, ?bathing need as mechanical/human help/physical assistance?. The ISP dated 7-14-22 did not identify a mechanical item. Resident is ?disoriented some spheres, sometimes?, the ISP did not document how resident should be redirected as needed. Resident?s behavior is assessed as, ?wandering, passively- weekly or more?. This need is not address on the ISP. The ISP documented behaviors of resistive to care and will try to hit and kick staff during showers. The UAI did not assessed aggressive behavior as an identified need. 6. On 8-23-22, resident #6?s UAI dated 6-1-22 documented bathing need assessed as ?mechanical help/human help/physical assistance?. The ISP dated 4-7-22 did not identify the mechanical item. 7. On 8-23-22, staff #1 and #2 acknowledged the aforementioned residents? ISP did not include all assessed needs.
Plan of Correction:	22VAC40-73-450-C Individualized service plans Date to be corrected: 10/12/2022 Resident #1?s ISP was updated to reflect all of resident current needs (9/2/22). Resident #2?s ISP was updated to reflect all of resident?s current needs (9/1/22). Resident #3?s ISP was updated (9/8/22) toreflect a need of ?mechanical and human help assistance for walking.? Resident #4?s ISP was updated (9/8/22) to reflect a need of ?mechanical and human help for stairclimbing.? Resident #5?s UAI and ISP was updated (9/9/22) to reflect the current needs of the resident. Resident #6?s UAI and IPS was updated (9/8/22) to reflect the current needs of resident. To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will conduct Individualized Service Plan audits on 3 residents monthly for two (2) months.
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his/her legal representative. Evidence: 1. On 8-23-22, resident #3?s ISP documented an update on 6-29-22. The updated ISP did not include a documented signature of the resident or legal representative. 2. On 8-23-22, staff #1 and #2 acknowledged the aforementioned residents? ISP did not include a required signature by the resident and/or legal representative.
Plan of Correction:	22VAC40-73-450-E Individualized service plans Date to be corrected: 10/12/2022 The resident #3?s individualized care plan (ISP) signed 7/25/22. Executive Director will train Health & Wellness Director, Health & Wellness Coordinator on individualized service plan process. The Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit on all residents individualized service plans to verify there is a signature and date. To assist with ongoing compliance, the Executive Director, Health & Wellness Director or Designee will conduct audits on all residents? annual individualized service plans & updated individualized service plan monthly for two (2) months to verify required signatures.
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all of the required information. Evidence: 1. On 8-23-22, following the medication pass observation, a review of the resident?s medication administration records (MARs) were conducted. Resident #1?s August 2022 MAR did not include the initials of the direct care staff administering the medications on 8-16-22 at 9:00 p.m. (Seroquel and Mirtazapine). The following tasks were not documented on the MAR: (a) Brushing teeth with electric toothbrush at 9:00 p.m. and (b) safety check at 10:00 p.m. 2. On 8-23-22, resident #2?s August 2022 MAR did not include the initials of the direct care staff administering the medications on 8-16-22 at 9:00 p.m. (Mirtazapine). The following tasks were not documented on the MAR: (a) Brushing teeth with electric toothbrush at 9:00 p.m. and (b) safety check at 10:00 p.m. 3. On 8-23-22, resident #3?s August 2022 MAR did not include the initials of direct care staff administering the medication on 8-16-22 at 9:00 p.m. (Calcium tablet, removing compression stockings, eye drops in both eyes and Trazadone tablet). Safety checks at 10:00 p.m. was not was not initialed on the MAR by direct care staff. 4. On 8-23-22, resident #4?s August 2022 MAR did not include the initials of direct care staff administering the medications on 8-16-22 at 2:00 p.m. (Seroquel). Safety checks at 10:00 p.m. on 8-11-22 and 8-16-22 were not initialed on the MAR by direct care staff. 5. On 8-23-22, resident #5?s August 2022 MAR did not include the initials of direct care staff administering the medication on 8-16-22 at 9:00 p.m. (cholesterol control -10 mg tablet and Melatonin). 6. On 8-23-22, resident #6?s August 2022 MAR did not include the initials of direct care staff signing and dating the MAR on 8-11-22 and 8-16-22 resident?s 10:00 pm safety check.
Plan of Correction:	22VAC40-73-680-I Administration of medications and related provisions Date to be corrected: 10/12/22 Registered Medication Aids & Licensed Practical Nurses will be retrained by Health & Wellness Director on initialing the medication administration record (MAR) after each medication is administered to resident in accordance with the physician order. Each off-going Registered Medication Aid /Licensed Practical Nurse will print missed medication report for on-coming Registered Medication Aid /Licensed Practical Nurse to review and sign. Resident Care Coordinator or designee will bring the missed medication report to the managers meeting every morning for review for two (2) months. To assist with ongoing compliance, the Health & Wellness Coordinator/designee will audit medication variance reports monthly for two months.