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: April 17, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/17/2023 from 09:15 AM until 04:45 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review and staff interview, the facility failed to ensure that prior to admission to a safe, secure environment, a resident shall have been assessed by an independent clinical psychologist authorized to practice in Virginia or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: 1. The record for resident 1 indicates that the resident was admitted to the facility on 09/13/2022 and is a resident in the safe, secure unit; however, the record does not contain an assessment by a clinical psychologist or an independent physician to show resident 1 as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. 2. Interview with staff 7 determined that this completed assessment form for resident 1 could not be found.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-1090-A ? Unable to retroactively correct the Serious Cognitive Impairment form for resident #1. ? MD was called to come and complete a new Serious Cognitive Impairment form on resident #1, resident #1 will not be returning. ? The Executive Director or designee will provide education for Sales Manager, Health and Wellness Director and Health and Wellness Coordinator on initial admission Serious Cognitive Impairment Form completion prior to admission no later than 5/31/2023. ? To assist with going compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will randomly audit 10% of current resident who continue to require a Serious Cognitive Impairment form prior to moving into a special care unit forms once a month for 3 months.
Standard #:	22VAC40-73-1110-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that six months after placement of a resident in the safe, secure environment the licensee, administrator, or designee performed a review of the appropriateness of a resident?s continued residence in the special care unit. EVIDENCE: 1. Resident 2 was admitted to the facility?s special care unit on 02/05/2022. The record for the resident did not contain documentation that a six-month review was performed by the licensee, administrator, or designee to determine the appropriateness of resident 2?s continued residence in the special care unit. 2. Interview with staff 7 confirmed that this documentation does not exist.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-1110-B ? Unable to retroactively correct the continued need for placement in a special unit form for resident #2. ? The most recent Continued Need for Placement in a Special Unit form was updated for resident #2 on prior to date of inspection on 4/17/2023. As well as current residents who reside on a special care unit. ? The Executive Director or designee will provide education to current Health and Wellness Director, Health and Wellness Coordinator on Continued need for special placement form and rating no later than 5/31/2023. ? To assist with going compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will randomly audit 10% of current resident who continue to require a special care unit for updated Continued need for placement forms once a month for 3 months.
Standard #:	22VAC40-73-120-C
Description:	Based on record review and staff interview, the facility failed to ensure that all staff shall receive orientation and training in all required areas of this standard within the first seven working days of employment. EVIDENCE: 1. The Record of Initial ALF Staff Training form for staff 1, 2, 3, 4, and 5 was incomplete and did not verify training in the relevant laws, regulations, and the facility?s policies and procedures to sufficiently implement the emergency and disaster plans for the facility, procedures for handling resident emergencies, use of the first aid kit and knowledge of its location, methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another, and for direct care staff, the needs, preferences, and routines of the residents for whom they will provide care. 2. Interview with staff 6 revealed that those staff members were not trained in those areas because there was no one to provide that training.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 4/17/2023. 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. 22VAC40-73-120-C Record of Initial ALF Staff Training Form ? Unable to retroactively correct the record of initial ALF staff training for staff #1, 2, 3, 4, and 5 or Affirmation date. ? The Executive Director or Designee will provide education for the Business Office Manager on the regulations and completion of the record of initial ALF staff training forms for staff #1,2,3,4, and 5 or affirmation is complete by 5/31/2023 ? The Business Office Manager or Designee will implement an ALF staff initial ALF training and checklist to verify the training is complete for staff # 1,2,3,4 and 5 or affirmation is complete by 5/31/2023. ? To assist with on-going compliance, The Executive Director or Designee will randomly audit the record for ALF initial staff training once a month for 3 months to verify completion of the ALF initial staff training forms.
Standard #:	22VAC40-73-270-1
Description:	Based on record review and staff interview, the facility failed to ensure that for direct care staff in assisted living facilities that accept, or have in care, residents who are or who may be aggressive or restrained, those staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states through information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior prior to being involved in the care of such residents. EVIDENCE: 1. In addition to regular assisted living, the facility also operates a safe, secure (memory care) unit which could contain residents with aggressive behaviors. 2. The record for staff 3, hired 12/20/2022, did not contain documentation of staff 3 having had the required aggressive behavior training. 3. Interview with staff 6 revealed that staff 3 did not have this training because there was no one available to teach it at the time that staff 3 began employment.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 4/17/2023. 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. 22VAC40-73-270-1 Direct Care Staff Training- Aggressive Behaviors ? Unable to retroactively correct the training record for staff # 3 or Affirmation Date. ? The Executive Director or Designee will provide Aggressive Behavior training to staff #3 on later than 5/31/2023. ? The Business Office Manager or Designee will inspect staff # 3 personal employee record to ensure completion of Aggressive Behavior training by 5/31/2023. ? To assist with on-going compliance, The Executive Director or Designee will randomly audit all Medication Technician new hire employee files for Aggressive Behavior training for 30 days.
Standard #:	22VAC40-73-325-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that there is documentation of interventions that were initiated to prevent or reduce risk of subsequent falls for a resident who meets the criteria for assisted living care. EVIDENCE: 1. The record for resident 5 contained staff progress notes and fall risk evaluations that the resident had a fall on the following dates: 02/15/2023, 02/17/2023, 02/25/2023, 03/02/2023, 03/11/2023, 03/15/2023, and 03/22/2023. 2. During the on-site inspection, collateral 2 informed staff 7 that the record for the resident did not contain documentation of interventions that were initiated to prevent or reduce risk of subsequent falls. 3. Staff 7 confirmed that this is accurate. No additional information was provided by the end of the on-site inspection.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-325-A Fall Risk Rating ? Unable to retroactively correct Fall Risk ratings for resident #5. ? The Fall Risk ratings was updated for resident #5 on date on inspection 4/17/2023. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will provide education to current nurses and RMA?s on Fall Risk rating no later than 5/31/2023. ? To assist with going compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will randomly audit 10% of current resident with falls for updated Fall Risk rating once a month for 3 months.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure prior to or at the time of admission to an assisted living facility that all required personal and social information on a person was obtained. EVIDENCE: 1. The resident-personal/social data sheets for residents 2 and 7 did not include information about the residents? current behavioral and social functioning that includes the residents? strengths and problems. 2. The resident-personal/social data sheet for resident 9 did not include information about interests/hobbies and strengths and problems.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-380-A Personal/Safety Data Sheet ? Immediate corrections were made to Personal/Social Data sheets for resident #2, 7, and 9 on day of inspection 4/17/23. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will provide education to current Sales Manager on the preadmission process and completion of the Personal/Social Data sheet no later than 5/31/2023. ? To assist with on-going compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit 50% of current resident with admissions greater than 30 days prior for completed Personal/Social Data sheets once a month for 3 months.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. EVIDENCE: 1. The individualized service plan (ISP) in the record for resident 8, dated 04/01/2023, indicates that the resident has a physician?s order and self-administers all of her medications; however, the UAI for the resident, dated 04/01/2023, indicates that the resident requires medications to be administered/monitored by a registered medication aide, licensed practical nurse or a registered nurse. 2. Interview with staff 7 confirmed that the resident self-administers all of her medications, so the ISP is correct and the UAI is incorrect.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-440-A The Uniform Assessment Instrument ? The Health and Wellness Director, Health and Wellness Coordinator or Designee will update resident # 8 Uniform Assessment Instrument (UAI) to reflect resident self-administration of medication and the Executive Director will review and sign no later than 4/19/2023. ? The Executive Director or designee will provide education for the Health and Wellness Director and Health and Wellness Coordinator on Uniform Assessment Instrument (UAI) and reflection of current resident needs no later than 4/28/2023. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit current Assisted Living resident?s Uniform Assessment Instrument (UAI) for current medication administration needs no later than 6/2/2023. ? To assist with ongoing compliance, the Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit and sign new or updated Uniform Assessment Instrument (UAI) upon completion for 3 months.
Standard #:	22VAC40-73-470-A
Description:	Based on resident record review, the facility failed to ensure that the health care service needs of residents were met. EVIDENCE: 1. The record for resident 6 contains documentation from 04/03/2023 that the resident was sent to the local emergency room due to a fall in which the resident hit her head and sustained a skin tear on her right hand and right leg. 2. The record for resident 6 contains documentation of a physician?s order, dated 04/12/2023, for home health to evaluate and provide wound care treatment to resident 6?s right hand and right leg. Facility progress notes, dated 04/15/2023, indicate that home health visited resident 6 on 04/15/2023. 3. From 04/03/2023 until 04/15/2023, the record for resident 6 does not contain documentation of physician?s orders or services being provided to meet the resident?s health care service needs for wound care treatments to the resident?s right hand and right leg.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-470A Health Care Services ? Unable to retroactively correct undocumented healthcare services and treatment for resident #6 on the dates of 4/3/2023-4/15/2023. Resident #6 currently receiving health care service by Third party home health services. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will provide education for nurses and RMA?s on obtaining and following through with treatment orders no later than 5/31/2023. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will review new orders of residents returning from outside services when returning from outside services within 24 hour of return. ? To assist with ongoing compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will randomly audit 10% of current resident with treatment needs once a week for (4) four weeks then monthly for 2 months.
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative or responsible individual. EVIDENCE: 1. The most recent annual review of resident rights located in the record for resident 5 was dated 03/15/2021. 2. The most recent annual review of resident rights located in the record for resident 9 was dated 11/12/2021. 3. Interview with staff 7 confirmed that these are the most recent reviews for those residents.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 4/17/2023. 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. 22VAC40-73-550-G Resident Rights and Responsibilities ? Unable to retroactively correct the resident?s rights and responsibility or affirmation date for resident #5. ? The Executive Director or Designee will provide education for the resident programming coordinator on the regulations and completion of the residents rights and responsibilities by 5/31/2023 ? The Executive Director or Designee will inspect resident #5 chart to ensure completion of Residents Rights and Responsibilities by 5/31/2023 ? To assist with on-going compliance, The Executive Director or Designee will randomly audit new residents records once a month for 3 months.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication carts and policy review, the facility failed to implement their medication management plan regarding methods to prevent the use of outdated medications and methods to ensure accurate counts of controlled substances. EVIDENCE: 1. Page 7 of the facility?s medication management plan, dated 10/2018, states that the medications that have expired or have discontinued will be disposed of per policy. 2. An open bottle of Brinzolamide 1% ophthalmic solution was observed on medication cart #2 for resident 3 on the day of inspection. The fill date from the pharmacy was noted to be 01/26/2023; however, the bottle did not contain a date that it was opened for use to ensure that the medication is disposed of within 4 weeks of use per manufacturer?s instructions. 3. The facility?s medication management plan, dated 10/2018, contained the following statement regarding counts of controlled substances: ?Will be counted by a licensed nurse/RMA from the off going [sic] shift and one from the oncoming shift. This procedure will occur at the beginning of each shift or whenever a change is made within that shift. Both staff?s signature and the count of bingo cards and sheets will be documented on either the Schedule II count sheet provided by the communities preferred pharmacy and the communities controlled Medication Inventory sheet.? 4. The ?Controlled Substance/MAR Change of Shift Audit? document for medication cart two did not contain the signature of the on-coming medication staff for 7-3 on 04/01/2023 and did not contain the signatures of the on-coming medication staff for 7-3 and the off-going medication staff for 3-11 on 04/10/2023 and 04/16/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure that a medication cabinet, container, or compartment that stores facility-administered medications and dietary supplements that are prescribed for residents shall be locked. EVIDENCE: At 03:46 PM on the date of inspection, LI observed an unattended unlocked medication cart outside of room 113. The same LI stood with the unlocked medication cart until staff 9 came out of room 113 at approximately 03:48 PM.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-660-A Storage of Medication ? Immediately corrected and medication cart # 2 secured at time of survey. ? Health and Wellness Director or designee will provide education on Storage of medication, corrective action and medication observation for associate # 9, completed no later than 4/28/2023. ? Executive director, Health and Wellness Director or designee will provide education for current LPN?s and RMA?s on Storage of Medication and the Importance of securing medication carts by 6/02/2023. ? To assist with ongoing compliance, the Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct Medication Observation for current LPN?s and RMA?s no later than 6/02/2023.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 7 contained physician?s orders, dated 03/01/2023 and 03/29/2023, for Hydralazine HCL 10 MG give one tablet every 8 hours as needed for HTN - systolic blood pressure (SBP) > 170 or diastolic blood pressure (DBP) > 105. 2. The March 2023 and April 2023 medication administration records (MARs) for resident 7 contained documentation that the resident?s blood pressure was 180/92 on 03/05/2023 and was 188/98 on 04/05/2023; however, neither MAR indicated that Hydralazine had been administered to the resident due to the systolic blood pressure being greater than 170 on both days. 3. Additionally, an interview with staff 7 indicated that there was no documentation to provide to the licensing inspectors during on-site inspection on 04/17/2023 to indicate that staff have been checking the resident?s blood pressure every eight hours to see if the resident requires the as needed Hydralazine HCL 10 MG.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure chemicals and other hazardous materials were stored in a locked area. EVIDENCE: At approximately 10:44 AM, collateral 2 noted that the door to the first-floor laundry room was unlocked and contained a container of Downy Unstoppables and a bag that contained All Free & Clear laundry detergent pods located inside of a laundry basket on the floor and a container of Caviwipes disinfecting towelettes located inside the cabinet on the back wall. All three items contained a warning to keep out of reach of children.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 4/17/2023. 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. 22VAC40-73-860-I CHEMICALS/HAZARDOUS MATERIALS STORED PROPERLY ? Unable to retroactively correct the chemicals stored in a locked AL area. ? Maintenance Director placed a lock on 1st floor Assisted Living Laundry Room door and a locked cabinet was purchased and placed in the laundry room to store these items. ? The Executive Director or Designee will provide education for the Maintenance and Housekeeping department on how to properly store Downy Unstoppables, detergent pods, and caviwipes. ? To assist with on-going compliance, the Executive Director or Designee will randomly inspect the laundry room and locked cabinet weekly for 4 weeks.
Standard #:	22VAC40-73-870-B
Description:	Based on observation during a tour of the building, the facility failed to ensure all buildings are well-ventilated and free from foul, stale, and musty odors. EVIDENCE: During the morning walk-through of the facility?s safe, secure unit, collaterals 1 and 2 and staff 8 noted a strong, foul smell in resident 12?s room and in resident 13?s room.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, are kept clean and in good repair and condition, except those furnishings and equipment owned by a resident is, at a minimum, in safe condition and not soiled in a manner that present a health hazard. EVIDENCE: At approximately 09:29 AM during on-site inspection, collaterals 1 and 2 and staff 8 noted that the seat cushion of the chair in resident 12?s room had a stain that covered a large area of the seat.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 4/17/2023. 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. 22VAC40-73-870E MAINTENANCE OF BUILDINGS AND GROUNDS ? Unable to retroactively correct the stain in the seat cushion in the resident?s room #12. ? The Executive Director or Designee will remove the stained cushion to be cleaned by 5/15/2023. ? The Executive Director or Designee will provide additional training on how to prevent and how to remove stains if possible for room #12, to be completed by 5/31/2023. ? To assist with on-going compliance, the Executive Director or Designee will randomly inspect residents room #12 once a week for 3 weeks.
Standard #:	22VAC40-73-930-D
Description:	Based on resident record review, document review and staff interview, the facility failed to ensure to document the rounds that were made, which included the date and time of the rounds and the staff member who made the rounds, for each resident with an inability to use the signaling device. EVIDENCE: 1. The individualized service plan (ISP) for resident 2, dated 04/10/2023, states that resident 2 will be rounded on every two hours to check for safety. 2. The continence care/two-hour rounding logs for resident 2 for April 2023 did not include documentation that staff made rounds on the resident every two hours during the 11:00 PM to 06:00 AM shift on the following dates: 04/02/2023, 04/06/2023, 04/10-12/2023, and 04/15-16/2023. 3. The ISP for resident 1, dated 03/24/2023, states that due to the diagnosis of dementia, resident 1 is unable to signal for help, and because of the inability to use the call bell, caregivers will round every two hours as needed to ensure resident safety. 4. The continence care/two-hour rounding logs for resident 1 for April 2023 did not include documentation that staff made rounds on the resident every two hours during the 11:00 PM to 06:00 AM shift hours on 04/06/2023. 5. The ISP for resident 9, dated 04/10/2023, states that due to the diagnosis of dementia, resident 9 is unable to signal for help, and because of the inability to use the call bell, caregivers will round every two hours as needed to ensure resident safety. 6. The continence care/two-hour rounding logs for resident 9 for the month of April did not include documentation that staff made rounds on the resident every two hours during the following dates and times: 04/06/2023 at 02:00 AM and 04:00 AM; 04/07/2023 at 02:00 AM and 04:00 AM; 04/10/2023 at 12:00 AM, 02:00 AM, and 04:00 AM; 04/11/2023 at 12:00 AM, 02:00 AM, and 04:00 AM; 04/15/2023 at 11:00 PM, 2:00 AM, 04:00 AM, and 06:00 AM; and 04/16/2023 at 11:00 PM, 2:00 AM, 04:00 AM, and 06:00 AM. 7. Interview with staff 7 confirmed that this was accurate.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 4/17/2023. 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 improvement to satisfy that objective. 22VAC40-73-930D Provisions for signaling and call systems ? Unable to retroactively correct two-hour safety checks for residents #1, #2, and #9. ? The Health and Wellness Director, Health Coordinator or Designee will place two-hour checks on MAR for resident #1, #2 and #9 to assist with staff coordination and monitoring of safety checks no later than 5/2/2023. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will provide education to current nurses and RMA?s on two-hour safety checks no later than 5/31/2023. ? To assist with going compliance, the Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will randomly audit 10% of current resident that require safety checks for signaling monthly for 3 months.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a sworn disclosure statement was completed for all applicants for employment. EVIDENCE: 1. The records for staff 10 who was hired on 11/07/2022, staff 11 who was hired on 08/04/2022, staff 12 who was hired on 11/01/2022, and staff 13 who was hired on 08/01/2022 did not contain documentation that a sworn statement or affirmation was completed prior to employment. 2. Interview with staff 6 revealed that these employees were previously employed at the facility and that a new sworn statement or affirmation was not completed at the time of their re-hire.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 4/17/2023. 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. 22VAC40-90-(BC2)-30-B Sworn Statement or Affirmation ? Unable to retroactively correct new hire Sworn Statement or Affirmation date for staff #10. ? The Executive Director or Designee will provide education for the Business Office Manager on the regulations and completion of the sworn statement or affirmation at the time of application and hire by 5/31/2023. ? The Business Office Manager or Designee will implement a new hire checklist to verify the sworn statement or affirmation is complete by 5/31/2023. ? To assist with on-going compliance, The Executive Director or Designee will randomly audit new hire paperwork to verify completion of the sworn statement or affirmation at the time of application and hire once a week for 2 months.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a criminal history report was obtained prior to the 30th day of employment for all staff. EVIDENCE: 1. The records for staff 10 who was hired on 11/07/2022, staff 11 who was hired on 08/04/2022, staff 12 who was hired on 11/01/2022, and staff 13 who was hired on 08/01/2022 did not contain documentation that a criminal history report was completed prior to their 30th day of employment. 2. Interview with staff 6 revealed that these employees were previously employed at the facility and that a new criminal history report was not obtained at the time of their re-hire.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 4/17/2023. 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. 22VAC40-90-(BC2)-40-B CRIMINAL HISTORY REPORT ? Unable to retroactively correct new hire Criminal History report or Affirmation for staff #10. ? The Executive Director or Designee will provide education for the Business Office Manager on the regulations and completion of the criminal history report or affirmation at the time of application and hire by 5/31/2023 ? The Business Office Manager or Designee will implement a new hire checklist to verify the criminal history report or affirmation is complete by 5/31/2023. ? To assist with on-going compliance, The Executive Director or Designee will randomly audit new hire paperwork to verify completion of the criminal history report or affirmation at the time of application and hire once a week for 2 months.