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. 26, 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 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

Personal Data

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: An unannounced renewal inspection took place on 10/26/223 from 8:20 am to 6:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 38 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. The call bell system was monitored. Additional Comments/Discussion: 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 (Donesia Peoples), Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Description:	Based on the record review and staff interviews the facility failed to ensure all staff who are mandated reporters under code 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. Evidence: 1. The record for resident #3 contains a progress note dated 10/08/23 documenting the following: ?resident #1 had hit resident #3 in his forehead with right side scarring, resident #1 was sent to the ER.? Resident?# 3 record contains a hospital discharge summary dated 10/08/23 documenting a diagnosis of ?abrasion of face.? Resident?s #1 record contains an incident report dated 10/09/23 documenting the following incident occurred on 10/08/23: ?resident #1 hit resident #3 above his eye with a rock that was wrapped inside of a napkin.? During an interview with staff #5, staff #5 reported resident #1 hit resident #3 in the face with a rock that was wrapped inside of a napkin on 10/08/23. Staff #5 confirmed the facility did not make an immediate report of suspected abuse as required under code 63.2-1606 of the Code of Virginia for the incident involving resident #3 to the local department or the Adult Protective Services hotline. 2. Staff #5 reported the incident to the Virginia Beach, Adult Protect Services unit on 10/26/23.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Nov 1, 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. The Executive Director/Health & Wellness Director or designee will conduct re-training to all mandated reporter staff members on reporting suspected abuse, neglect and neglect. Staff #5 reported incident to Adult Protective Services on 10/26/23 and will use incident check list for all abuse incidents moving forward. To assist with ongoing compliance, the Executive Director/Health & Wellness Director or designee, will verify, weekly for two (2) months, that any incidents of suspected abuse, neglect, or exploitation of residents, has been reported timely. Plan of correction to be completed January 8, 2024.
Standard #:	22VAC40-73-310-H
Description:	Based on the record review the facility failed to ensure in accordance with 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans. Evidence: 1. The record for resident #1, admitted 10/06/23, contains a physical examination completed on 10/04/23 documenting the resident was prescribed the following psychotropic medications: Haldol 0.5mg, PRN for mood/agitation and Seroquel 25 mg at bedtime for agitation. Resident?s #1 record did not contain a treatment plan dated prior to or on admission for the psychotropic medications, Haldol 0.5mg and Seroquel 25mg.
Plan of Correction:	The Executive Director, Health & Wellness Director and Health & Wellness Coordinator, will be re-trained, by the District Director of Clinical Services (DDCS) or designee, on having physician complete psychotropic treatment plan form prior to admitting residents who take psychotropic medications. The Health & Wellness Director/Health & Wellness Coordinator or designee will conduct an audit on all resident?s charts who take psychotropic medications to verify psychotropic treatment plans are in place. In addition, to verify ongoing compliance, the Sales Manager will add Psychotropic treatment plan form to the admissions documents. The Executive Director/Health & Wellness Director or designee will conduct audits of new resident move-in documents, weekly, for the next two (2) months to verify psychotropic treatment plans are in place. Plan of correction to be completed by January 8, 2024.
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident. Evidence: 1. The record for resident #5 contains a risk assessment for TB dated 06/16/22. The facility provided evidence of a risk assessment for TB completed on 10/26/23 for resident #5, however the risk assessment was completed after the annual due date of 06/16/22.
Plan of Correction:	The Health & Wellness Director, Health & Wellness Coordinator and Resident Care Coordinator will be re-trained, by the DDCS, on annual TB risk assessments. The Health & Wellness Director/Health & Wellness Coordinator or designee will conduct audits on all resident?s charts to verify residents have TB risk assessments completed. The Health & Wellness Director or designee will have a physician complete any needed TB risk assessments. To assist with ongoing compliance, the Executive Director or designee will conduct an audit on all resident?s charts weekly for the next two (2) months to verify that TB risk assessments are completed. Plan of correction to be completed January 8, 2024.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: a description of identified needs based upon the Uniform Assessment Instrument (UAI), physical examination, and other sources. Evidence: 1. The record for resident #2 contains a Do Not Resuscitate Order (DNR) dated 03/10/21. Resident?s #2 ISP dated 09/28/23 documents the resident code status as Full Code. 2. The record for resident #6 contains a DNR dated 03/25/16. Resident?s #6 ISP dated 04/28/23 documents the resident code status as Full Code. 3. Resident?s #1 physical examination dated 10/04/23 documents the resident?s dietary needs as the following: 2mg sodium diet, soft and bite size. Resident?s #1 ISP dated 10/06/23 does not include the resident?s dietary needs as documented on the physical exam. 4. Resident?s #1 UAI dated 10/06/23 documents mechanical and human help needed for walking. The resident?s ISP dated 10/06/23 does not include the human help support needed for walking.
Plan of Correction:	The Health & Wellness Director/Health and Wellness Coordinator or designee will conduct an audit on all current resident charts to verify that the resident code status matches throughout the resident?s medical record. The Health & Wellness Director/Health & Wellness Coordinator or designee will complete an audit of all current resident charts to verify dietary needs on History & Physical is documented within the individual service plan (ISP). Resident #4 Uniform Assessment Instrument (UAI) will be updated to reflect the need for mechanical help as indicated on the ISP. The Health & Wellness Director/Health & Wellness Coordinator or designee will conduct an audit on each residents UAI and ISP to verify the mechanical and human assistance needs are consistent. To assist with ongoing compliance, the Executive Director and Health & Wellness Director will conduct audits on new admission records, monthly for two (2) months, to verify that the code status match throughout the resident?s medical records. Plan of correction to be completed January 8, 2024.
Standard #:	22VAC40-73-550-G
Description:	Based on the resident record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal guardian or responsible individual. Evidence: 1 The record for resident #5 contains an annual review of the rights and responsibilities of residents dated 01/31/22. The facility provided evidence of a review of rights and responsibilities of residents reviewed for resident #5 dated 10/21/23, however the review was completed after the annual due date of 01/31/22.
Plan of Correction:	Business Office Manager & Programs Manager will be re-trained on tracking annual resident rights and confirming that each resident or legal representative have been consulted with annually. The Programs Manager/Business Office Manager or designee will conduct an audit on each resident?s chart to verify resident rights have been reviewed and signed by the resident or legal representative. The Programs Manager or Business Office Manager or designee will document these annual meetings and will obtain written acknowledgment from each resident or legal representative of having been so informed, which shall include the date of the review and shall be filed in the resident's record. Plan of correction to be completed January 8, 2024.
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in order. Evidence: 1. The facility?s medication management plan includes the following statements: medications that have expired or have been discontinued will be disposed of per policy; when a new order/order change is received by the community, the nurse or RMA will fax a copy to the appropriate pharmacy and enter the changes in Point Click Care. 2. During observation with staff #4 the following expired medications were observed in the medication cart: Morphine Sulfate Syringes ( 3 packs of 10) expired 08/02/23 for resident #8. 3. The record for resident #1 contains a physician order dated 10/23/23 to discontinue the resident?s medication, Protonix. Resident?s #1 MAR documents the resident was administered the medication on 10/25/23 and the MAR does not include documentation the medication was discontinued on 10/23/23.
Plan of Correction:	Resident #8 morphine was taken off of the medication cart by HWD on 10/26/23 and disposed. All new orders will be entered by a licensed nurses and then verified by the Health & Wellness Coordinator and or the Health & Wellness Director or designee. ED to retrain HWD &HWC on medication cart audit, transcription of medications and discontinuing medications. To assist with ongoing compliance the Health and Wellness Coordinator or designee will audit medication carts weekly for the next two (2) months. Plan of correction to be completed January 8, 2024.