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: Oct. 31, 2022 , Nov. 1, 2022 , Nov. 2, 2022 and Nov. 17, 2022

Complaint Related: No

Areas Reviewed:

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

Comments:

Type of inspection: Renewal An unannounced renewal inspection was conducted on-site on 10-31-22 (ar 08:15/dep 17:25) and 11-01-22 (ar 08:55/dep 16:55). The facility census was 29. A tour of the facility was conducted, medication pass observation with staff, staff and resident records reviewed, breakfast meal observed, an spiritual morning activity with exercise observed, emergency preparedness items reviewed (food, fire drill, emergency preparedness and first aid kits check conducted). An exit meeting conducted with the administrator on both days with violations reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure admit or retain individuals with any prohibitive conditions or care needs. Evidence: 1. On 10-31-22, resident #2?s October 2022 medication administration record (MAR) and physician order dated 9-21-22 documented resident prescribed Trazadone. The record did not include a psychotropic treatment plan.
Plan of Correction:	Resident number 2?s physician will create a psychotropic treatment plan based on her visit with Resident number 2 at the community on December 7, 2022. -Health & Wellness Director, Health & Wellness Coordinator, or designee will complete an audit of resident records for those resident with an order for a psychotropic medication to verify each resident has a psychotropic treatment plan. -To assist with ongoing compliance, the Executive Director or designee will complete an audits on new residents records monthly, for the next 3 months to verify a psychotropic treatment plan is in place for any resident with an order for a psychotropic medication.
Standard #:	22VAC40-73-350-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it ascertain prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days. Evidence: 1. On 10-31-22, resident #5?s record documented the resident?s date of admission as 12-14-21. The sex offender document was dated 1-6-22. 2. Staff acknowledged the sex offender information was not obtained prior to admission.
Plan of Correction:	Executive Director or designee will audit current resident records to verify they have a registered sex offender check in their resident record. Executive Director or designee will note on the registry check, if it was ran after date of admission. -To assist with ongoing compliance, the Executive Director or designee will audit new residents records monthly for 3 months to verify if the sex offender registry check was completed for residents with a length of stay greater than 3 days.
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 two of five records reviewed. Evidence: 1. On 10-31-22, resident #1?s uniform assessment instrument (UAI) dated 9-10-22 noted stairclimbing assessed as no need. The individualized service plan (ISP) dated 9-10-22 documented stairclimbing as mechanical help/physical assistance needed. 2. Resident #2?s UAI dated 9-20-22 assessed eating/feed need as mechanical help. The ISP dated 3-3-22 did not include this need. Resident?s UAI documented disorientation to time, place and situation. The ISP did not include how staff should re-orient resident. The record included a signed and dated Do Not Resuscitate (DNR) order dated 4-21-22, the ISP documented resident is a Full Code. 3. Staff acknowledged the aforementioned residents? ISPs 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 November 17, 2022. 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 Health & Wellness Director, Health & Wellness Coordinator, or designee will update resident #1?s uniform assessment instrument (UAI) and individuals service plan (ISP) to reflect the resident?s current stairclimbing needs. The Health & Wellness Director, Health & Wellness Coordinator, or designee will update resident #2?s UAI & ISP to reflect the resident?s current eating/feeding needs. Resident #2?s ISP will be updated to include how staff shall re-orient resident. ?Resident #2?s ISP will be updated to reflect resident?s current Code status. The Health & Wellness Director, Health & Wellness Coordinator, or designee will complete an audit on all current resident records to verify that the resident?s Code status is updated on residents? records and ISPs. To assist with ongoing compliance, the Health & Wellness Director, Health & Wellness Coordinator, or designee will complete an audit of ten (10) resident records monthly for 3 months to verify that both UAIs & ISPs reflect current resident assessed needs.
Standard #:	22VAC40-73-640-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure its medication management plan was implemented. Evidence: 1. On 10-31-22 during medication pass observation with staff #4, resident #1?s 2022 medication administration record (MAR) documented resident prescribed Artificial Tears. The medication was not available to avoid a missed dosage/administration. 2. Resident #2?s Miralax was not available to avoid a missed dosage. 3. Resident #3 had medication on the cart that were no longer prescribed: Meloxicam and Tizanidine. These medications were recommended during the pharmacy review (5-4-22) to be discontinued for non-use in over 90 days and agreed to by the prescriber on 6-16-22. 4. Staff #4 acknowledged scheduled medications for residents #1 and #2 were not available and medications for resident #3 that were discontinued were on medication cart #2.
Plan of Correction:	Resident #1?s artificial tears was ordered and is available on the medication cart. Resident #2?a Miralax was ordered and is available on the medication cart. Resident #3?s Meloxicam and Tizanidine were removed from the medication cart. -Health & Wellness Coordinator completed audit of medications on the medication cart to verify it was consistent with residents? medication administration record (MAR). To assist with ongoing compliance, a medication cart audit will be completed monthly for 3 months, by the Health and Wellness Director, Health and Wellness Coordinator, or designee to verify the residents? MAR is consistent with the medications in the medication cart and physician orders.
Standard #:	22VAC40-73-680-M
Description:	Based on document review, observation and staff interviewed, the facility failed to ensure medications ordered for PRN (as needed) administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 10-31-22, during medication pass observation with staff #4, a review of the October 2022 medication administration record (MAR) for resident #1, the following PRNs were not available: Miralax, Sugar Free Gum and Tylenol. 2. Resident #2?s PRN Trazadone, Tylenol and Refresh eye-drops were not available. 3. Resident #3?s Imodium was not available. 4. Resident #4?s Calmoseptine not available. 5. Staff #4 acknowledged the aforementioned residents? PRN medications were not available during the medication cart check on 10-31-22.
Plan of Correction:	Resident #1?s PRN Miralax, Nicotine Gum and Tylenol were ordered and are available on the medication cart. Resident #2?s PRN trazadone, Tylenol and refresh eye-drops were ordered and are now available on the medication cart. Resident #3?s Immodium was ordered and is available on the medication cart. Resident #4?s calmoseptine was ordered and is available on the medication cart. -To assist with ongoing compliance, the Health & Wellness Coordinator completed an audit of medications on the medication cart to verify it was consistent with residents? medication administration record (MAR). To assist with ongoing compliance, a medication cart audit will be completed monthly for 3 months, by the Health and Wellness Director, Health and Wellness Coordinator, or designee to verify the MAR is consistent with the medications in the medication cart and physician orders.