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: Sept. 1, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

870

Comments:

A complaint (#55966) was received by VDSS Division of Licensing on 08/11/2022 and 09/01/2022 regarding allegations in the area(s) of: Interior building condition, potentially hazardous items and areas of the facility being accessible to cognitively impaired residents, neglected housekeeping duties, residents not receiving at least two baths/showers per week, and unmet resident incontinence needs. Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were validated. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required. EVIDENCE: The UAI for resident 1, dated 08/04/2022, was incomplete regarding the Behavior Pattern of this resident. This UAI also indicated that resident 1 is disoriented to some spheres, all the time; however, the spheres affected were not entered. This UAI indicated that resident 1 needs help with transferring, but the type of help needed is not completed. Finally, this UAI indicated that resident 1 needs help with stairclimbing, but the type of help needed is not completed.
Plan of Correction:	? The Uniform Assessment Instrument (UAI) for Resident 1 will be reviewed by the Health and Wellness Director, Executive Director or Designee and will be updated to reflect current behavior pattern, disorientation to spheres and assistance needed for stairclimbing and transferring. Expected outcomes and completion no later than 10/24/2022. ? The Executive Director or designee will provide education for the Health and Wellness Director and or Designee on Uniform Assessment Instrument (UAI) compliance by 10/30/2022 ? The Health and Wellness Director or Designee will perform an audit of all current residents Uniform Assessment Instrument (UAI) for current resident behavior patterns, orientation status, ADL assistance, and to ensure completion of UAI to be completed by 10/30/2022. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit current residents Uniform Assessment Instrument (UAI) for identified resident behaviors and completion of UAI once a month for three months.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. EVIDENCE: 1. The UAI and ISP for resident 1, dated 08/04/2022, indicated that resident 1 is incontinent of bladder weekly or more. For toileting, resident 1 requires the mechanical assistance of grab bars, staff assistance to remind resident to go to the bathroom every few hours, and staff to ensure resident has changed protective undergarments. 2. The AM, PM, and Night shift Toileting/Incontinence Care log for resident 1 for August 2022 did not contain documentation of staff performing toileting/incontinence rounding for the following dates and times: From 07:00 AM ? 12:00 AM on 08/01/2022; From 12:00 AM ? 10:00 PM on 08/02/2022; From 07:00 AM ? 12:00 AM on 08/03/2022; From 12:00 AM ? 06:00 AM on 08/04/2022; From 07:00 PM ? 10:00 PM on 08/11/2022. 3. The ISP for resident 1, dated 08/04/2022, indicated that resident 1 requires the mechanical assistance of grab bars and a shower bench with staff physical assistance to shower with set up and selection of laying out showering supplies. The ISP also indicated that bathing services will be provided on Wednesdays and Saturdays. 4. Interview with staff 1 on the date of inspection indicated that Skin Integrity Monitoring forms are used to document when a resident receives assistance for bathing as well as for any skin condition changes observed by staff during that time. 5. Based on documented Skin Integrity Monitoring forms for resident 1 from 05/29/2022 ? 09/03/2022, resident 1 received a bath or shower or attempts were made on the following dates: 07/02/2022, 07/23/2022, 07/27/2022, 07/30/2022, 08/06/2022, and 08/13/2022. The Skin Integrity Monitoring form dated 07/09/2022, states ?Resident combative to RMA and caregiver?. 6. The UAI, dated 10/05/2021 and the ISP, last updated 12/20/2021, for resident 2 indicated that resident 2 is incontinent of bladder and bowel weekly or more and requires the mechanical assistance of grab bars and staff physical assistance for toileting and changing protective undergarments. 7. The AM, PM, and Night shift Toileting/Incontinence Care log for resident 2 for August 2022 did not contain documentation of staff performing toileting/incontinence rounding for the following dates and times: From 04:00 PM ? 12:00 AM on 08/01/2022; From 12:00 AM ? 06:00 AM and 04:00 PM ? 11:00 PM on 08/02/2022; From 04:00 PM ? 10:00 PM on 08/03/2022; From 04:00 PM ? 11:00 PM on 08/11/2022. 8. The ISP for resident 2, last updated 12/20/2021, indicated that resident 2 requires the mechanical assistance of grab bars, staff set-up, and physical assistance for showers. The ISP also indicated that bathing services will be provided on Wednesdays and Saturdays. 9. Interview with staff 1 on the date of inspection indicated that Skin Integrity Monitoring forms are used to document when a resident receives assistance for bathing as well as for any skin condition changes observed by staff during that time. 10. Based on documented Skin Integrity Monitoring forms for resident 2 from 05/29/2022 ? 09/03/2022, resident 2 received a bath or shower on the following dates: 06/11/2022, 06/25/2022, 07/02/2022, 07/07/2022, 07/13/2022, 07/23/2022, 07/27/2022, 07/30/2022, 08/06/2022, 08/13/2022, 08/20/2022, 08/22/2022, and 08/27/2022.
Plan of Correction:	? The Executive Director, Health and Wellness Director or designee will review Skin Integrity documents and Toileting schedules for residents number 1 and 2 no later than 10/24/2022 ? The Executive Director or designee will provide education for the Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator on Skin Integrity documents & Toileting schedules no later than 10/24/2022. ? The Executive Director, Health and Wellness Director, Health and wellness Coordinator or designee will audit current resident?s records for Skin Integrity documents and resident records with Toileting schedules no later than 10/31/2022. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit 5% of current resident?s records for Skin Integrity documents & Toileting schedules once a month for two months.