VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Harrisonburg
2101 Deyerle Avenue
Harrisonburg, VA 22801
(540) 574-2982

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: April 25, 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 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

Technical Assistance:

Ensure resident social data sheet has all areas complete. Ensure all areas of Serious Cognitive Impairment Form (SCI) are complete.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Two Lis conducted a renewal inspection on 04/25/2023. 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: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: fire drills, menu, activities calendar, dietary and healthcare oversight, pharmacy review. A medication pass was also observed by the LI. 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on review of residents? records, the facility failed to ensure all assessed needs are identified on the ISP. EVIDENCE: 1. The UAI for resident 1, dated 10/03/2022 indicates supervision is needed with stairclimbing. This is not reflected on the ISP dated 09/28/2022. 2. The ISP for resident #3 dated 11/16/2022 indicates resident is a full code. Resident #3 has a DNR effective 03/14/2023. 3. The UAI for resident #4, dated 01/20/2023 Indicates mechanical assistance is needed with dressing, toileting and mobility. The ISP dated 01/20/20/2023 indicates resident is independent. 4. The UAI for resident #4, dated 01/20/2023 Indicates only mechanical assistance is needed with bathing. The ISP dated 01/20/2023 indicates mechanical assistance as well as supervision is needed. 5. The UAI for resident #4, dated 01/20/2023 Indicates only mechanical assistance is needed with stairclimbing. This is not indicated on the ISP date 01/20/2023.
Plan of Correction:	The Executive Director, Health and Wellness Director or designee will update the Individualized Service Plans with current care needs for resident?s number 1, 3, and 4 by 5/31/2023. The Executive Director or designee will provide education for the Health and Wellness Directors, Health and Wellness Coordinators on Individualized Service Plans and Care needs by 5/31/2023. The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit current residents Individualized Service Plans and Care needs by 8/11/2023. To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans and care needs monthly for two months.
Standard #:	22VAC40-73-450-D
Description:	Based on review of residents? records, the facility failed to ensure hospice services are included on the Individualized Service Plan. EVIDENCE: Resident #1 receives hospice services effective 04/13/2023. This is not included on the resident?s ISP dated 09/28/2022.
Plan of Correction:	The Executive Director, Health and Wellness Director or designee will review and update the Individualized Service Plans with current care needs and third party services for resident?s number 1 by 5/31/2023. ? The Executive Director or designee will provide education for the Health and Wellness Directors, Health and Wellness Coordinators and Resident Care Coordinator on Individualized Service Plans requirements and Third Party Care Services by 5/31/2023. ? To assist with ongoing compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit Individualized Service Plans and Third Party Care Services for current residents by 8/11/2023.
Standard #:	22VAC40-73-660-B
Description:	Based on observations made during the tour of the building and resident record review, the facility failed to ensure there were no medications in residents? rooms for one resident who is rated depended in medication administration. EVIDENCE: 1. Resident #5 has a Uniform Assessment Instrument (UAI) dated 11/10/2022 which documents medication administration is performed by a layperson in the facility. 2. Resident #5 was being observed by the LI during the morning medication pass. The LI observed a cup of gel on the bedside table. 3. Resident #5 and staff #2 confirmed substance as Voltaren Gel. 4. Resident #5?s file does not contain a physician?s order to allow this resident to self-administer any medication.
Plan of Correction:	The Executive Director, Health and Wellness Director or designee immediately removed Voltarin gel from resident # 5 apartment. ? The Health and Wellness Director or designee will provide re-education on medication administration and orders and complete medication administration observation for associate # 2 no later than 5/31/2023. ? The Executive Director, Health and Wellness Director or designee will provide re-education for current LPN?s and RMA?s on medication administration and not leaving medication at bedside by 6/01/2023. ? To assist with ongoing compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct Medication Administration Observation for current nurses and RMA?s no later than 6/01/2023.
Standard #:	22VAC40-73-700-1
Description:	Based on document review, the facility failed to ensure physician?s orders for oxygen included all required components. EVIDENCE: 1. The physician order for resident #1 dated 04/06/2023 does not identify the oxygen source. 2. The physician order for resident #7 dated 05/05/2022 does not identify the oxygen source.
Plan of Correction:	? Unable to retroactively correct original Oxygen order for resident #1. ? The Health and Wellness Director or designee received updated Oxygen order for resident #1 on day of survey 4/25/23. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator or designee will audit and, if needed, obtain orders identifying oxygen source for all residents with oxygen orders by 5/15/2023. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator or designee will provide re-education to current nurses and RMA?s accepting orders on proper parameters for oxygen orders by 6/1/2023
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to ensure the interior of the building is maintained in good repair and kept clean. EVIDENCE: During a walk through of the facility, the bathroom sink in room #205 was observed to have standing water and not draining properly; the toilet paper holder broken and a strong smell of urine.
Plan of Correction:	? The Executive Director or designee will implement a work order request and tracking system for associates to report needed repairs to the Maintenance Manager to allow maintenance repairs to take place in a timely manner by 5/15/2023. ? The Executive Director or Designee will provide reeducation on timely reporting of maintence repairs for current associates no later than 6/1/2023. ? To assist with ongoing compliance, The Executive Director or Designee with randomly audit maintenance repair reporting for timeliness and repairs monthly for 2 months.