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: March 7, 2024

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 03/07/2024 08:40am to 2:40pm 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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-350-B
Description:	Based on resident record review and staff interview, the facility failed to ensure prior to admission whether a potential resident is a registered sex offender. EVIDENCE: 1.The record for resident 1, admission date 2/29/2024, contained a Virginia State Police Sex Offender search result dated 3/7/2024. 2.During the on-site inspection on 3/7/2024, an interview conducted with one Licensing Inspector and staff person 4, staff person 4 revealed the record for resident 1 was current.
Plan of Correction:	1. Resident number 1, admission date admitted 2/29/2024. The Business Office Manager (BOM) immediately requested and obtained sex offender information and placed in business file. 2. All current resident business files were audited by the BOM to verify completion and placement of sex offender documentation. 3. Executive Director or designee to provide reeducation for BOM on obtaining sex Offender information under regulation 22VAC40-73-350B. 4. To assist with ongoing compliance, Executive Director or designee will audit all new resident business files weekly for four (4) weeks.
Standard #:	22VAC40-73-950-E
Description:	Based on facility record review and staff interview, the facility failed to ensure the semi-annual review on emergency preparedness and response plan was signed by residents. EVIDENCE: 1. The facility record contained documentation of the review being completed on 2/6/2024, however there was no documentation of resident signatures who participated. 2.During the on-site inspection on 3/7/2024, an interview conducted with one Licensing Inspector and staff person 4, staff person 4 revealed the facility record was current.
Plan of Correction:	Unable to retroactively correct date of completion for the emergency preparedness plan. 2. Executive Director or designee will provide reeducation for Maintenance Manager on emergency preparedness plan requirements under regulation 22VAC40-73-950E. 3. Maintenance Manager or designee will complete a review of the emergency preparedness plan with all resident?s and or responsible parties as applicable and obtain signatures. 4. To assist with ongoing compliance, the Executive Director or designee will review emergency response plan documentation once a month for two (2) months.