Brookdale Lake Ridge
3940 Prince William Parkway
Woodbridge, VA 22192-4513
(703) 680-0600
Current Inspector: Jeffrey Marnien (540) 571-0189
Inspection Date: Aug. 15, 2024
Complaint Related: No
- Areas Reviewed:
-
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 BUILDINGS AND GROUND
- Technical Assistance:
-
n/a
- Comments:
-
Type of inspection: Other
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/15/2024 12:37pm ? 4:00 pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 6/25/2024 regarding allegations in the area of: Resident Care
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: 1
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 4
Observations by licensing inspector: A tour of the memory care unit was conducted.
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violation Notice Issued: Yes
- Violations:
-
Standard #: 22VAC40-73-300-B Description: Based on record review and staff interview the facility failed to have a method of written communication to keep direct care staff on all shifts informed of significant happenings or problems experienced by residents during each shift.
Evidence:
1. Resident 1 eloped on 6/24/2024 during the second shift (3:00pm ?11:00pm) from the special care unit. The approximate time of elopement is between 6:30pm and 7:00pm.
2. The LI requested copies of the communication log from June 20, 2024, to June 27, 2024.
3. The communication log on June 24, 2024, did not include written documentation of the elopement during the 3:00pm-11:00pm and 11:00pm ? 7:00am shifts.
4. The 6/25/2024 communication log documented the elopement during the 7:00am-3:00pm shift. The LI asked Staff 6 how the staff on 6/25/2024 would be made aware of the elopement if it was not documented on 6/24/2024 and the response was Staff 8 called in the next morning to communicate the elopement to the nurse.
5. The LI requested a copy of the facility staff communication policy. The facility provided policy: Alert Charting ? 3 as their policy for shift communication. The policy describes the nurse or designee should document in the resident record. It also states associates should notify the nurse of conditions or events and the nurse should enter information in the Alert Charting Log.
6. Staff 4 and Staff 6 acknowledged that only nurses document in the communication log. They also acknowledged that the communication log did not communicate the elopement for each shift.Plan of Correction: ? Unable to retroactively correct staff communication report for resident number 1.
? The Executive Director, Health and Wellness Director or Designee will initiate a communication log to keep direct care staff informed of significant situations during each shift.
? The Executive Director, Health and Wellness Director or designee will provide reeducation for all associates on staff communication report of significant situations.
? To assist with ongoing compliance, The Health and Wellness Director or Designee will audit communication log daily time 2 weeks and weekly thereafter.
Standard #: 22VAC40-73-460-D Description: Based on record review and interviews the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises.
Evidence:
1. Resident 1 UAI (date: 5/19/2024) identified resident as disoriented to place, time, and situations all of the time. Approved level of care was memory care.
2. A Brief Interview Mental Status Screening (BIMMS) tool was administered (date 4/16/2024) to Resident 1 who scored 1, denoting severe cognitive impairment.
3. Assessment of serious cognitive impairment (date 3/8/2024) administered by a licensed psychologist identified Resident 1 as unable to recognize danger or protect their safety and welfare.
4. A incident report notifying Resident 1 eloped was submitted by Staff 5 to the Region 3 Licensing Administrator on 6/25/2024.
5. The LI requested a copy of the facilities internal investigation which included the following timeline: on 6/24/2024, dinner trays were reportedly picked up from memory care around 5:30pm and the front concierge desk was staffed until 6:30pm and the concierge did not see Resident 1 walk past the desk.
6. Collateral 1 reported to the LI, at approximately 8:15pm Collateral 1 received a call from a pedestrian who saw Resident 1 crossing the street at an apartment complex. The pedestrian approached Resident 1, identified resident needed assistance, noticed a bracelet with contact information on resident's wrist and called Collateral 1. The apartment complex is located approximately 1.5 miles from the facility. At approximately 8:20pm Collateral 1 called the facility and asked Staff 8 why Collateral 1 had not been notified that Resident 1 was not in the facility. Resident 1 was returned, by Collateral 1, to the facility at approximately 8:35pm the same day.
7. Noted in the facilities Incident Investigation Report, page 3 of 6, was a note that the pass code to the memory care unit had been given to a non-associate.
8. The Post Elopement investigation report includes a question if a security report was ran to ensure equipment was working properly and to determine how often the doors were opened? This question was marked ?yes?. The LI questioned Staff 5, who completed the report, and Staff 5 could not explain why ?yes? was entered when a report could not be run. Staff 7 was also questioned, and Staff 7 also reported that a report could not be run and entering ?yes? should not have been entered.
9. Staff 5 acknowledged to the LI during an interview on 8/15/2024 that the exact events and time that Resident 1 exited the building could not be determined. Staff 5 stated that a family member had access to the pass code to the secure unit should not have happened. Staff 5 stated the exact whereabout of the resident between dinner and when Collateral 1 called the facility notifying Resident 1 was not in the facility makes knowing how long the resident was outside the facility difficult. Staff 5 acknowledged that lapses occurred allowing the resident to exit the building unsupervised.Plan of Correction: ? Unable to retroactively correct that an unauthorized individual had door code for the safe, secure unit.
? The Executive Director, Health and Wellness Director or designee immediately updated memory care door codes and secured special care unit.
? The Executive Director or designee will provide education for the Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator and clinical associates on safe, secure environment and that only staff is to have memory door codes.
? To assist with ongoing compliance, The Executive Director, Maintenance Manager, Health and Wellness Director, Health and wellness Coordinator or designee will audit memory care alarms, appropriate door codes, and frequent resident rounds weekly for 4 weeks, then monthly thereafter.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.