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: Nov. 28, 2023

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 11/28/23 from 9:45 am to 3:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/09/2023 regarding allegations in the area(s) of: Resident Care and Related Services and Personnel. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of lunch and an activity were completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations, area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violations not related to the complaint 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: Resident?s #2 ISP dated 10/10/23 was not signed by the facility and the resident or the legal guardian.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Dec 4, 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. Resident was discharged from facility on 11/21/22. Health and Wellness Director (HWD) and Health and Wellness Coordinator (HWC) in-services on ISP process and signature. HWD, HWC or designee will complete an audit on all residents ISPs to ensure signatures are present. Executive Director or designee will do random audits for the next two 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, including assistance or care with bathing, at least twice a week but more often if needed or desired. Evidence: 1. Resident?s #2 Individualized Services Plan (ISP) dated 10/10/23 documents the resident requires physical assistance with bathing to be provided by Direct Care Staff two times a week and as needed. Resident?s #2 bathing logs are dated as completed on 10/23/23, 11/02/23, 11/06/23, and 11/08/23. The facility did not provide documentation resident #2 received assistance with bathing, twice a week during the following timeframes: 10/10/23 through 10/23/23; 10/23/23 through 11/02/23; 11/08/23 through 11/22/23.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Dec 4, 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. On December 15, 2023 the care staff will be educated on correct shower days for each resident and the reporting process. The shift lead will verify that the showers are being completed per the Virginia Assisted Living Standards and lease agreement. HWD, HWC or designee will complete random audits to ensure all resident showers are completed twice weekly.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the facility the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years. Evidence: 1. Resident?s #2 ISP dated 10/10/23 documents ?resident has a pull cord in room and bathroom, due to cognitive impairment & functional decline, may not remember to use. Staff to do rounds every 2 hours.? Resident?s #2 record did not include documentation rounds were made for the month of October and November 2023. 2. Resident?s #4 ISP dated 10/05/23 documents ?staff to do rounds every two hours when asleep in bed & frequent rounding throughout the day. Has a pull cord, due to cognitive impairment & functional decline will not remember to use.? Resident?s #4 record did not include documentation rounds were made for the month of October and November 2023.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated Dec 4, 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. Staff will be educated on the process and documentation of resident rounds every two hours during the evenings. HWD or HWC will enter rounds into the electronic medication administration system (EMAR) for each new resident. Nurses and Registered Medication Aids (RMA) will document in the EMAR system as rounds are completed. HWD or HWC will complete an audit to ensure each resident has the required rounding schedule entered into the EMAR system. Executive Director will do random audits of the EMAR to ensure rounds are entered on new residents for two months.