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: Dec. 5, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint 58505 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/05/2023 from 10:00 AM until 01:00 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 10/30/2023 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s). Area(s) of non-compliance with standard(s) or law were: Resident care and related services. A violation notice was issued; any violation(s) not related to the complaint(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) contained an accurate description of identified needs and who will provide services to address those needs based on information obtained from all sources. EVIDENCE: 1. The UAI and ISP for resident 3 indicates that the resident requires mechanical assistance and supervision with bathing. The ISP indicates that resident 3 requires supervision assistance with turning the water on and off, adjusting water temperature, shampooing, blow-drying hair, washing upper and lower extremities, and towel drying and dressing. The ISP also indicates that resident 3 will use the shower chair/grab bars for mechanical assistance. The ISP states that a facility caregiver or resident 3 will provide the service of bathing/showering two days weekly. 2. An interview with staff 1 and staff 2 revealed that resident 3?s bath or shower is usually provided by her daughter or other family member and is sometimes completed on her own, but each bath or shower is to be documented by staff. 3. A telephone interview between LI and the daughter of resident 3 confirmed that the daughter usually comes each week to give her a bath or shower, but sometimes she will ask staff to assist resident 3 if she cannot make it to the facility. 4. Staff 1 and staff 2 acknowledged that resident 3?s ISP does not indicate that the daughter or other family members are regularly providing the service of bathing/showering.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 12/5/2023. 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. 22VAC40-73-450-C ? The Individualized Service Plan (ISP) for resident #3 will be reviewed by Executive Director and signed for approval and the ISP for resident # 3 will be updated to reflect residents? daughter may assist with showers upon visits. ? The Health and Wellness Director will review all current residents? whom may receive assistance from outside agency or family (caregiver) to update ISP with additional assistance. ? The Executive Director will provide education for the Health and Wellness Director and Health and Wellness Coordinator on ISP compliance by 1/10/2024. ? To prevent recurrence, RCC, HWD, or designee will audit all current ISP?s in the next 30 days to ensure any caregiver provided additional assistance has been listed on the ISP. When ISP?s are completed ED or designee to review and sign as well. HWD or designee will audit ISP?s weekly. ED will audit ISP at least weekly (3/10/24).
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that personal assistance and care are provided to the resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week. EVIDENCE: 1. The uniform assessment instrument (UAI) and individualized service plan (ISP) for resident 1 and resident 2 indicate that each require physical assistance with bathing. 2. The UAI and ISP for resident 3 indicates that the resident requires mechanical assistance and supervision with bathing. 3. An interview with staff 1 and staff 2 indicated that the facility uses designated shower sheets to record twice weekly resident bathing/showers, laundry, and skin breakdown for those residents who require assistance with those activities. 4. Upon a review of daily shower sheets for resident 1 for September and October 2023, LI observed that showers were documented as completed on 09/13/2023 and 10/28/2023. 5. Upon a review of shower sheets for resident 2 for September and October 2023, LI observed that showers were documented as completed or refused x3 on 9/7/2023 (refused x3), 9/11/2023, 9/18/2023, 9/21/2023, 9/25/2023, 10/2/2023, 10/9/2023, 10/16/2023, and 10/30/2023. 6. Upon a review of shower sheets for resident 3 for September and October 2023, LI observed that showers were documented as completed by self, family, or refused on 9/18/2023 given by ?self/family?, 9/21/2023 given by ?self?, 9/28/2023 ?refused?, 10/2/2023 by ?self?, and 10/16/2023 by ?daughter?. 7. Further interview with staff 1 and staff 2 revealed that no other shower sheets were found for residents 1, 2, and 3 to ensure that they received showers at least twice weekly during the sampled time period.
Plan of Correction:	The following is the Plan of Correction for Brookdale Salem, Virginia regarding the Statement of Deficiencies dated 12/5/2023. 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. 22VAC40-73-460-H ? Shower sheets for the residents will be reviewed by Resident Care Coordinator or designee and placed in a binder directly labeled for identification. ? The Health and Wellness Director or designee will review all current residents? shower schedule and audit shower sheets for completion daily x30 days. ? The Health and Wellness Director will provide education for the clinical nursing team on shower sheet compliance by 1/10/2024. ? To prevent recurrence, RCC, HWD, or designee will audit all shower sheets for the next 30 days to ensure completion of shower sheets and proper filing. When shower sheets are completed ED or designee to review as well. HWD or designee will audit shower sheets daily .ED will audit shower sheets at least weekly (3/10/24).