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. 22, 2023

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 08/22/23 from 8:40 am to 11:10am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 08/09/2023 regarding allegations in the area(s) of: Personnel, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 7 Observations by licensing inspector: An observation of building and grounds to include resident rooms and common areas. An observation of breakfast was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on the record review the facility failed to ensure direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health institute, community college, hospital, volunteer rescue squad, or fire departments. Evidence: 1. The record for staff #1, hire date 09/06/22, contains a certification in first aid from the American Red Cross completed on 02/24/21, valid for 2 Years (expired 02/24/23). The record does not contain a current certification in first aid. 2. Staff # 6 emailed the Licensing Inspector on 08/24/23 a sign in sheet dated 06/13/23 titled CPR Training which included the name and signature of staff #1, however the facility did not provide evidence of staff #1 maintaining certification in first aid after the date of 02/24/23.
Plan of Correction:	?Staff #1 took the First Aid and CPR course on 6/13/23, we received a copy of the certification on 8/31/23. ?The Business Office Manager (BOM) was retrained on tracking Employees First Aid & CPR certification by Executive Director on August 28, 2023. ?BOM or designee will complete an audit of all associate files to verify First Aid and CPR certifications are up to date. ?BOM or designee will schedule a First Aid and CPR class for September 18, 2013, for any associate requiring recertification. ?To assist with ongoing compliance, once a month for three (3) months, the BOM or designee will complete an audit of associate files to verify the First Aid and CPR certifications are up to date.