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: June 14, 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 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

Technical Assistance:

None

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/14/2024 08:35am ? 02:08pm 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: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight. Additional Comments/Discussion: none 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on record review and staff interview, the facility failed to review and update the fall risk rating after a fall. Evidence: 1. Resident 1 had a documented fall on 4/29/2024, Resident 2 had a documented fall on 5/16/2024, Resident 3 had a documented fall on 5/23/2024 and resident 4 had a documented fall on 1/1/2024. 2. Upon request the facility did not provide a fall risk assessment after each fall. 3. Staff 2 stated ?We don?t do those?
Plan of Correction:	The Executive Director, Health and Wellness Director or designee will update the Individualized Service Plans with Fall Risk Ratings for residents with falls during the last 12 months by 8/2/2024. The Executive Director or designee will provide re-education for the Health and Wellness Directors, Health and Wellness Coordinators on the practice of completing and adding the fall risk rating to the Individualized Service Plans by 7/5/2024. To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans monthly for three months.
Standard #:	22VAC40-73-410-A
Description:	Based on record review and staff interview, the facility failed to ensure that the orientation to the facility be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: 1. Resident 1 admitted 5/3/2023 has a resident orientation signed only by staff #1. There is no signature of the resident or responsible party present. 2. Resident 2 admitted 6/22/23 has a resident orientation that is not signed by the resident. 3. Upon request the facility did not provide a resident orientation for resident 3 admitted 5/19/2022. 4. Staff 3 stated during an interview that they could not find the orientation for Resident 3.
Plan of Correction:	The Executive Director, Business Office Manager or designee will audit all resident files for completed resident orientations by 8/2/2024. The Executive Director, Business Office Manager or designee will complete all missing or incomplete resident orientations by 8/2/2024. The Executive Director or designee will provide re-education for the Health and Wellness Directors, Health and Wellness Coordinators, Business Office Manager and Sales Director on the practice of completing the resident orientation on admission by 7/5/2024. To assist with ongoing compliance, The Executive Director or designee will audit all admissions for Resident Orientation completion for three months
Standard #:	22VAC40-73-450-F
Description:	Based on record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) was updated following a change in condition. Evidence: 1. Resident 2 has a physician?s order for home health services dated 1/4/2024. The ISP for resident 2 dated 3/8/2024 does not include home health services. 2. Staff 2 stated resident 2 is still receiving home health services
Plan of Correction:	The Executive Director or designee will provide re-education for the Health and Wellness Directors, Health and Wellness Coordinators and Resident Care Coordinators on Individualized Service Plans requirements and Third Party Care Services by 7/5/2024. 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 8/2/2024. To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans monthly for three months
Standard #:	22VAC40-73-700-1
Description:	Based on record review and staff interview, the facility failed to ensure oxygen orders contain all required information. Evidence: 1. Resident 5 has a physician?s order for oxygen dated 04/24/2024 that states ?Oxygen on 3 Liter while sleeping via nasal canula at bedtime for hypoxia? 2. The oxygen order does not contain the oxygen source. 3. Staff 2 stated in an interview that they were unaware of the oxygen order requirements.
Plan of Correction:	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 7/5/2024. 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 7/5/2024