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: Nov. 15, 2022

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: 11/15/2022 9:30am until 4:30pm 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: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 13 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 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 #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall contain all required components which include significant medical history, any diagnosis or significant problems, and a statement that specifies whether the individual is considered ambulatory or non-ambulatory. EVIDENCE: 1. The record for resident 9, admitted 01/31/2022, contained a ?Physician/Healthcare Provider Plan of Care? physical examination form which indicated that the physician visit occurred on 08/05/2021 but was signed by a physician on 02/08/2022. This form did not indicate if the individual has any significant medical history, if there are any diagnoses or significant problems, or if the individual is considered ambulatory or non-ambulatory.
Plan of Correction:	The following is Brookdale Danville Piedmont, formerly known as Abingdon Place of Danville, Plan of Correction to the Department of Social and Health Services Statement of Deficiencies dated November 15, 2022. 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. Executive Director (ED)/designee will re-educate staff responsible for reviewing admission paperwork for completeness of required information on the physicians plan of care. ED/designee will review new admissions to verify diagnoses and ambulatory status is indicated. To assist with ongoing compliance the ED/Health and Wellness Director (HWD)/designee will review the physician plan of care prior to admission weekly for four (4) weeks
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure the fall risk rating was updated for residents after a fall. EVIDENCE: 1. The record for resident 3 contained documentation by facility staff, dated 10/30/2022, that the resident fell on 10/29/2022 and was sent to the emergency room due to head injury; however, the most recent fall risk completed for the resident was dated 05/18/2022. Interview with staff 4 revealed that there is not an updated fall risk rating to reflect the fall from 10/29/2022. 2. Progress notes for resident 5, dated 11/04/2022, indicated that the resident had fallen on that date; however, the most current fall risk evaluation completed by the facility was dated 10/12/2022.
Plan of Correction:	ED/HWD/designee will re-educate direct care staff regarding the fall risk rating updated after each fall. HWD/designee will review current residents fall documentation to verify the fall risk rating has been updated. To assist with ongoing compliance the ED/designee will review a sample of resident fall documentation to verify fall risk ratings is up to date, weekly for four (4) weeks.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure prior to or at the time of admission, the required personal and social information for a resident was obtained. EVIDENCE: 1. The resident-personal social data document for resident 1 does not include document regarding the following: service in armed forces (if applicable), information on advance directives, DNR orders, or organ donations (if applicable), clergyman/place of worship (if applicable), next of kin (if known), and the address, phone number and cell phone number for the resident?s personal physician and person dentist. 2. The record for resident 3 contains a signed physician?s order, dated 11/08/2022, that the resident has an allergy to Sulfa Antibiotics and this allergy is also included on the resident?s November 2022 medication administration record; however, the resident-personal social data document for the resident indicates that the resident has no allergies.
Plan of Correction:	ED/designee will re-educate staff responsible for assisting in the admission process information regarding personal and social information to be obtained for each resident. ED/designee will review new admission documentation to verify that the resident personal social data form is completed. To assist with ongoing compliance, the ED/designee will review personal social data form weekly for four (4) weeks.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure for private pay individuals, the uniform assessment instrument (UAI) was completed as required. EVIDENCE: 1. The UAI for resident 3, dated 12/01/2021, did not contain documentation regarding if the resident does or does not require assistance with eating/feeding.
Plan of Correction:	HWD/designee will review current resident UAI?s and update as determined appropriate. HWD/designee will re-educate direct care staff who complete UAI?s on the Uniform Assessment Instrument. To assist with ongoing compliance the HWD/designee will review a random sample of resident UAI?s weekly for four (4) weeks
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The UAI (uniform assessment instrument) for resident 1, dated 11/01/2022, indicates that the resident requires mechanical help with transferring; however, this identified need is not indicated on the resident?s ISP dated 11/01/2022. Interview with staff 4 confirmed that the resident does require mechanical help with transferring. 2. The UAI for resident 3, dated 12/01/2021, indicates that the resident requires mechanical help and supervision with bathing; however the ISP for the resident, dated 12/01/2021 is inconsistent as it indicates that the resident requires mechanical help and physical assistance with bathing. Interview with staff 4 revealed that the UAI is correct. The ISP for resident 3 also indicates that the resident is receiving physical and occupational therapy services and wears a right wrist splint due to a fracture; however, interview with staff 4 revealed that the resident no longer receives physical and occupational therapy services and no longer wears a right wrist splint. 3. Interview with staff 5 revealed that the facility indicates on a resident?s ISP if they have an allergy. The record for resident 3 contains a signed physician?s order, dated 11/08/2022, that the resident has an allergy to Sulfa Antibiotics and this allergy is also included on the resident?s November 2022 medication administration record; however, the aforementioned allergy is not indicated on the resident?s ISP. 4. The ISP for resident 6, dated 08/18/2022, indicates that the resident receives oxygen therapy two liters per minute as ordered by his physician; however, the ISP does not indicate what the oxygen source is. 5. The record for resident 5 contained therapy progress notes which indicated that wound care therapy had started on 11/09/2022; however, the ISP for resident 5, dated 10/11/2022, was not updated to reflect this need. Also, the uniform assessment instrument for resident 5, dated 10/12/2022, states that the resident requires mechanical assistance for dressing, walking, and mobility; however, the ISP for resident 5, dated 10/11/2022, did not address these needs. 6. The UAI dated 08/25/2022 in the record for resident 2 has documentation that the resident requires physical assistance with wheeling, transferring, bowel and bladder and is disoriented to some spheres some of the time with place and time being the spheres affected. Also the record for resident 2 has documentation that the resident uses a halo device on their bed. The ISP dated 07/12/2022 in the record for resident 2 does not address these identified needs.
Plan of Correction:	HWD/Designee will review resident ISP?s and update to reflect services being provided to resident. HWD/designee will review ISP?s during care plan meetings as well as during Collaborative Care Meetings held bi- monthly to verify the accuracy of the assessment. To assist with ongoing compliance the ED/designee will audit monthly for three (3) months to verify services on ISP.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure that the menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. EVIDENCE: 1. While completing a tour of the physical plant on the date of inspection, collateral 2 observed that the posted weekly menu was from the week of October 9, 2022 ? October 15, 2022, and the posted weekly snack menu was from July 3, 2022 ? July 30, 2022.
Plan of Correction:	Dining Services Manager/Designee will check for compliance of menus for meals and snacks for the current week are posted in an area conspicuous to residents. To assist with ongoing compliance ED/Designee will review menus and snack postings to verify compliance, weekly for four (4) weeks.
Standard #:	22VAC40-73-640-A
Description:	Based on medication cart audits, resident record review and staff interview, the facility failed to implement components of their medication management plan. EVIDENCE: 1. The facility?s medication management plan states the following: ?A medication cart audit occurs quarterly and is completed by the HWD/RCC or their designee. An audit requires removal and reorder of all expired medications. The HWD/RCC will review the forms after the audit has been completed.? and the plan indicates that for medication refill orders medication staff are responsible for monitoring the needs for refills and the pharmacy should be notified when a seven day supply is remaining. 2. The Mount Cross medication cart contained a container of Bisacodyl 10MG suppositories as needed for constipation for resident 12; however, the medication expired on 06/30/2022 and also contained a bottle of Prednisone 10MG tablets for resident 3; however, the prescription was filled on 10/19/2022 and only contained 10 tablets for the resident to take within 5 days with a start date of 10/19/2022. 3. The November 2022 medication administration record (MAR) for resident 4 indicates that the resident is to receive Neutrogena Hydro Boost body gel cream applied to both legs topically for dryness and keratosis daily at 8:00PM; however, from 11/02/2022 through 11/14/2022 the aforementioned cream has not been applied due to pharmacy action required. An interview with staff 1 confirmed that the cream was not available at the facility during on-site inspection. 4. The Mount Cross medication cart contained an opened vial of Novolin insulin for resident 13 that did not contain the open date for the insulin. The manufacturer instructions for Novolin insulin states that the insulin is only good for 42 days once opened. 5. The T-Bird medication cart contained an opened bottle of Latanoprost Sol eye drops for resident 2. The bottle did not contain a date that the medication was opened. Manufacturer instructions are to discard within 6 weeks of opening this medication. 6. The T-Bird medication cart contained an opened Levemir insulin pen and a opened Novolog insulin pen for resident 10. The pens did not contain dates that they were opened. Manufacturer instructions are to discard Levemir insulin pens 42 days after opening and to discard Novolog insulin pens 28 days after opening. 7. The T-Bird medication cart contained an opened Basaglar insulin pen and an opened Lantus Solostar insulin pen for resident 11. The insulin pens did not contain the date that they were open. Manufacturer instructions are to discard these insulin pens 28 days after opening. 8. The control count sign sheet for the Mount Cross and the T-Bird medication carts were missing signatures for multiple shifts from 11/1/2022 through 11/15/2022. The facility medication management plan has documentation that ?Both staff signatures and the count of bingo cards and sheets will be documented on either the schedule 2 count sheet provided by the communities preferred pharmacy and the communities controlled medication inventory sheet?.
Plan of Correction:	HWD/ED/Designee will conduct quarterly medication cart audits and remove medications that are expired and check to verify medications are available and labeled with open dates on insulins and eye drops. To assist with ongoing compliance the HWD/ED/Designee will audit medication carts weekly for four (4) weeks, to verify compliance and review substance count sheets when medication administration staff changes.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record reviews, the facility failed to ensure that physician orders were maintained in resident records. EVIDENCE: 1. A physician order dated 08/11/2022 to change the diet for resident 8 from a puree diet to a regular diet was not located in the record for resident 8 on the day of inspection.
Plan of Correction:	HWD/ED/Designee will review current resident diet orders for compliance with physicians orders. To assist with ongoing compliance, the HWD/ED/Designee will review diet orders weekly for four (4) weeks to verify
Standard #:	22VAC40-73-680-B
Description:	Based on observations of the facility medication carts, the facility failed to ensure that all medication remained in the pharmacy issued container with prescription label until administered to the resident. EVIDENCE: 1. A Lantus Solostar insulin pen was observed on the T-Bird cart without a pharmacy prescription label or resident name. 2. 1 green and 2 white pills were observed lying loose in the bottom of the second drawer of the T-Bird medication cart. 3. A yellow gel capsule was observed lying loose in the bottom of the second drawer of the Mount Cross medication cart.
Plan of Correction:	HWD/designee will re-educate staff administering medications regarding proper labeling of medications stored in the medication cart. To assist with ongoing compliance, the HWD/designee will audit medication carts weekly for four (4) weeks
Standard #:	22VAC40-73-680-M
Description:	Based on a medication cart audit, resident record review and staff interview, the facility failed to ensure medications ordered for as needed administration (PRN) were available at the facility. EVIDENCE: 1. The record for resident 3 contained a physician?s order, dated 11/08/2022, for Benzonate 200MG one capsule every 8 hours as needed for cough and Ondansetron 4MG one tablet every 6 hours as needed for nausea. Staff 1 revealed that the aforementioned PRN medications were not available at the facility during on-site inspection.
Plan of Correction:	HWD/ designee will re-educate registered medication aide staff on having prn medications available for use. To assist with ongoing compliance, the HWD/Designee will audit medication carts weekly for four (4) weeks
Standard #:	22VAC40-73-700-2
Description:	Based on observations of the building, the facility failed to post ?No Smoking-Oxygen in Use? signs in a room of the building where oxygen is in use. EVIDENCE: 1. At approximately 9:41AM, one licensing inspector (LI) observed resident 4 using oxygen in her room and multiple portable oxygen tanks. There was not a ?No Smoking-Oxygen in Use? sign posted at the room.
Plan of Correction:	HWD/Designee will re-educate direct care staff regarding posting of No Smoking Oxygen in Use Signs when oxygen is in use. HWD/Designee will review residents on oxygen for signage of No Smoking Oxygen in Use Signs in rooms/doors
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure that the interior of all buildings shall be maintained in good repair. EVIDENCE: 1. While completing a tour of the physical plant on the date of inspection, collateral 2 observed that the wall on the left side of the dining room, next to a table and chair, had a long scratch in which a layer of paint was removed. 2. In the conference room/therapy room on the left back side of the building, collateral 2 also observed that a portion of the ceiling was broken and a portion of the ceiling contained a dark stain around a vent.
Plan of Correction:	Maintenance Director/ED will repair scratch in wall in the left of the dining room and ceiling in therapy room around vent. To assist with ongoing compliance, the Maintenance Director will inspect the community building routinely for damages to walls and ceilings ekly for four (4) weeks