VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Danville Piedmont
149 Executive Court
Danville, VA 24541
(434) 799-1930

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Dec. 12, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/12/2023 8:45am until 2:30pm 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: 46 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: 1 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated when a significant change in a resident occurred. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 03/18/2023 in the record for resident 3 has documentation that the resident requires physical assistance with dressing and transfers and is disoriented to some spheres some of the time with place and time being the spheres affected. The record for resident 3 also has a physician order dated 03/17/2022 and 11/10/2023 that the resident is on a texture modified diet. The ISP dated 07/06/2023 in the record for resident 3 does not address or provide documentation of services to be provided for these identified needs. 2. The UAI dated 01/02/2023 in the record for resident 5 has documentation that the resident requires mechanical assistance with dressing. The record also has a do not resuscitate (DNR) order signed by the physician on 11/28/2023. The ISP dated 01/02/2023 in the record for resident 5 does not address or provide documentation of services to be provided for these identified needs.
Plan of Correction:	The following is the Brookdale Danville Piedmont Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated December 12, 2023. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions outlined in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or findings. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. ?The Health and Wellness Director (HWD)/Designee will review all resident Individualized Service Plans (ISPs) and verify the diet orders and services. ?Direct care associates were retrained ISP requirements. This retraining was completed on 12-14-2023 by the Executive Director. ?The ISP of Resident 3 and 5 were updated on 12-13-2023 by the HWD. ?HWD/designee will review resident ISPs during care plan meetings as well as during Collaborative Care Meetings, to verify the accuracy of the assessment. ?To assist with ongoing compliance, the Executive Director (ED)/designee will audit all Resident ISPs monthly for two (2) months to verify ISPs are up to date.
Standard #:	22VAC40-73-610-D
Description:	Based on observations and staff interviews, the facility failed to ensure that a special diet ordered by a physician was prepared and served according to physician orders. EVIDENCE: 1. The record for resident 3 has a physician order dated 03/17/2023 and again on 11/10/2023 that the resident is to receive a texture modified diet. The special diet board in the kitchen also has documentation that resident 3 is on a texture modified diet. The licensing inspector (LI) observed resident 3?s breakfast meal sitting on a bedside table in front of the resident on the day of inspection. 2 slices (strips) of bacon were observed on the styrofoam container. An interview was conducted with staff 6 on the day of inspection in which staff 6 expressed that slices/strips of bacon is not considered a texture modified diet.
Plan of Correction:	?Resident 3?s ISP was updated to show current diet order on 12-13-2023. ?Direct care associates were retrained by HWD on 12-14-23 regarding serving diets as indicated in the physician order(s). ?HWD/designee will review all diet orders and confirm the residents ISPs reflects any physician prescribed diet order. ?To assist with ongoing compliance, the HWD/designee will review diet orders weekly for four (4) weeks to verify the diet order is correct in the resident?s ISP.
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review and staff interviews, the facility failed to follow their medication management plan in regard to the ordering of medications. EVIDENCE: 1. The facility medication management plan has documentation that ?if a medication is not available at the scheduled time of administration the pharmacy will be notified, an entry will be made in the resident log notes in the medical file and the HWD/RCC or their designee will be notified. Charting ?medication not available? on the MAR alone does not fulfill this requirement. 2. The December 2023 medication administration record (MAR) for resident 3 has a physician order dated 12/08/2023 for Cipro 500mg oral tablet, give one tablet by mouth two times a day for UTI for 7 days. Staff initials and the number 16 are listed on the MAR from 12/08/2023 through 12/12/2023 with explanation that pharmacy action is required. An interview with staff 5 on the day of inspection expressed that they were not made aware that the Cipro 500mg medication was not currently in the facility and that the medication was ordered by Hospice and the Hospice pharmacy was supposed to deliver the medication.
Plan of Correction:	?Hospice was contacted regarding medication for resident 3 on 12-12-23 ?Retraining was completed on 12-14-2023 by the HWD regarding medications being available to follow prescribers orders ?To assist with ongoing compliance, the HWD/ED/designee will conduct a weekly. medication cart audit for four (4) weeks to verify Resident medications are available.
Standard #:	22VAC40-73-680-C
Description:	Based on observations of the facility morning medication pass, the facility failed to ensure that medications were administered not later than one hour after the facility standard dosing time. EVIDENCE: 1. The scheduled 8am medications for resident 3 were not administered until 9:18am on the day of inspection. 2. The scheduled 8am Gabapentin 300mg for resident 4 was not administered until 9:25am on the day of inspection. 3. The scheduled 8am medications for resident 1 were not administered until 9:44am on the day of inspection.
Plan of Correction:	?Medications were administered on 12-13-2023 for Resident 3, Resident 1 and Resident 4. ?HWD/designee will re-train direct care staff on medication administration time frames. ?To assist with ongoing compliance, the HWD/designee will audit all resident MARs weekly for four (4) weeks to verify medications are being administered within timeframes.