VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Midlothian
14016 Turnberry Lane
Midlothian, VA 23113
(804) 897-8884

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: June 27, 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 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility from 10:00a ? 1:40p 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: 78 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: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Additional Comments/Discussion: 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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on a review of resident records the facility failed to ensure that the order of priority was followed prior to placement in a secure safe environment. Evidence: An uncle was the listed on the written approval form for resident #5. There was no documentation as to why the order of priority was not followed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records the facility failed to document the results of a tuberculosis risk assessment. Evidence: An admission tuberculosis screening form for resident #6 dated 3/14/22 indicates the risk results are ?pending?. The results were not updated and recorded.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records the facility failed to complete an annual risk assessment on each resident. Evidence: Resident #6 was admitted to the facility on 3/16/22 . There is no documented annual tuberculosis risk assessment in the resident record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-430-H-1
Description:	Based on a review of resident records the facility failed to retain a written discharge statement in the resident record. Evidence: There was no discharge statement in the record for resident #9.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records the facility failed to complete comprehensive service plans within in 30 days after admission. Evidence: An initial service plan for resident #8 was completed on 5/17/22 and comprehensive service plan was not developed until 7/6/22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of resident records the facility failed to have Individualized service plans signed and dated by the resident or their legal representative. Evidence: Current ISP? s were not signed or dated for residents #2,3,4,6,7,8.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of resident records the facility failed to ensure that a Do Not Resuscitate Order was included in the Individualized Service Plan for each resident. Evidence: A service plan for resident #7 was completed on 4/19/23 that states CPR will be performed. A DNR order was issued on 4/27/22 and the service plan was not updated to reflect the change.
Plan of Correction:	Not available online. Contact Inspector for more information.