VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Roanoke
1127 Persinger Road, S.W.
Roanoke, VA 24015
(540) 343-4900

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Feb. 27, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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 SANCTIONS.

Technical Assistance:

380-A

Comments:

The LI for Brookdale Roanoke, along with two additional LIs, conducted an unannounced renewal study on 02/27/2020 from 8:45AM until 3:30PM, finding 42 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and an activity. Eight resident records were thoroughly reviewed, and an additional five were partially reviewed in relation to the observation of the medication pass and/or special diets. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of four staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator and Director of Nursing on the date of inspection where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection.The LIs provided technical assistance regarding obtaining personal and social information on residents prior to or at the time of admission. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-120-A
Description:	120-A Based on staff record review, the facility failed to ensure that all required components of orientation and training were completed within the first seven days of employment. EVIDENCE: 1. The RECORD OF INITIAL ALF STAFF TRAINING for staff 9 showed FIRST DAY OF WORK as 11/18/2019 however the DATE(S) OF TRAINING & TRAINER?S INITIALS section did not contain initials or dates of when the training had been completed. The student transcript for staff 9 from www.healthstream.com did not contain the following required orientation training: the purpose of the facility, the facility?s organizational structure, the services provided, the daily routines, the facility?s policies and procedures, specific duties and responsibilities of their positions, required compliance with regulations for assisted living facilities as it relates to their duties and responsibilities, procedures for handling resident emergencies, requirements regarding the rights and responsibilities of residents, procedures for reporting and documenting incidents as required in 22 VAC 40-73-70, methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another and for direct care staff, the needs, preferences and routines of the residents for whom they will provide care. 2. The record for staff 10 (date of hire 02/12/2020) did not contain a RECORD OF INITIAL ALF STAFF TRAINING. The student transcript for staff 10 from www.healthstream.com did not contain the following required orientation and training: the purpose of the facility, the facility?s organizational structure, the services provided, the daily routines, the facility?s policies and procedures, specific duties and responsibilities of their positions, required compliance with regulations for assisted living facilities as it relates to their duties and responsibilities, procedures for handling resident emergencies, requirements regarding the rights and responsibilities of residents, procedures for reporting and documenting incidents as required in 22 VAC 40-73-70, methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another and for direct care staff, the needs, preferences and routines of the residents for whom they will provide care.
Plan of Correction:	LI is aware new BOC in place within community. Initial new hire orientation paperwork was completed and updated prior to LI closing out day. BOC/designee will utilize Revised New Hire State Orientation form to easily demonstrate state required training orientation completed, BOC will training forms and updated as necessary. BOC/designee to review new hire training records to ensure orientation requirements are met prior to new hire working their assignment. ED/designee to sign off on New Hire records, along with 7 day orientation per state and Brookdale policies.
Standard #:	22VAC40-73-250-C
Description:	250-C Based on review of staff record, the facility failed to maintain personal and social data on a staff member. EVIDENCE: 1. Interview with staff 12 revealed that staff 1 ended employment with the facility on 05/9/2019 and was rehired on 06/13/2019. The following information was not updated by the facility for staff 1: date employed, verification that staff 1 had received a copy of current job description, sworn disclosure statement, original criminal record report and documentation of orientation, training, and education requirements. 2. Interview with staff 12 revealed that staff 1 stated the former executive director of the facility ?never took her (staff 1) out of the system and did not terminate her when she left and just let her come back, as it was so quick?.
Plan of Correction:	Records for Staff 1 and Staff 2 reviewed, completed with documentation. BOC/designee to audit employee records and update as necessary. BOC/designee to review staff records to ensure personal and social data page requirements are met. ED/designee to review 10% of employee records monthly for compliance.
Standard #:	22VAC40-73-250-D
Description:	250-D Based on review of staff records and staff interviews, the facility failed to ensure that staff, prior to coming in contact with residents, submitted the results of a tuberculosis risk assessment (TB) that was no older than 30 days. EVIDENCE: 1. Date of hire for staff 5 was 11/14/2019. The NEW HIRE/ANNUAL EMPLOYEE SCREENING AND PPD OR CHEST X-RAY results that staff 5 submitted to the facility was dated as being administered on 06/17/2019 and read on 06/19/2019. 2. Date of hire for staff 6 was 11/14/2019. The NEW EMPLOYEE TUBERCULOSIS SCREENING, P.P.D/CHEST X-RAY RECORD results that staff 6 submitted to the facility was dated as being administered on 07/15/2019 and being read on 07/17/2019. 3. Date of hire for staff 7 was 09/15/2019. The MANTOUX TUBERCULIN SKIN TEST RECORD FORM results that staff submitted to the facility was dated as being administered on 07/16/2019 and being read on 07/18/2019. 4. Date of hire for staff 8 was 05/25/2019. The QUANTIFERONR-TB GOLD PLUS, 4T, INCBATED results that staff 8 submitted to the facility was dated 01/19/2019. 5. Interview with staff 12 revealed that staff 1 ended employment on 05/09/2019 with the facility and was rehired on 06/13/2019. There was no new TB risk assessment conducted.
Plan of Correction:	Records for Employee 5,6,7,8,and 12 reviewed and updated annual TB requirements. Community to maintain bi annual rotation for compliance as needed. BOC /designee will audit 10% employee records per month for new hire employee records reviewed by ED prior to Employee completing floor orientation. New employees to have final new hire welcoming/onboarding with ED/Designee. ED/designee will track new hire orientation for completion prior to 1st day working independently. BOC/designee will schedule review with ED to obtain feedback related to training and, orientation process.
Standard #:	22VAC40-73-410-A
Description:	410-A Based on resident record review, the facility failed to ensure that a new resident orientation was completed upon admission. EVIDENCE: 1. The record for resident 3, admitted on 01/23/2020, contained an incomplete new resident orientation form.
Plan of Correction:	New Admission packets will include Orientation form to be completed at time of admission. Resident #3 record was reviewed and ED reviewed record and orientation record with family. ED/designee to review new admission records including orientation to community within 3 days of admission. Ed/designee will re-train staff on new admission orientation for residents and families. ED/designee will audit 10% of resident records monthly for compliance of state and Brookdale standards. Date corrections completed within each file.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on resident record reviews, the facility failed to ensure that all identified needs were addressed on comprehensive individualized service plans. EVIDENCE: 1. The record for resident 3 contains documentation for physical therapy starting on 2/4/2020, occupational therapy starting on 1/30/2020, and speech therapy starting on 2/4/2020, but the therapy services are not included on the most current ISP in the record, dated 1/30/2020. 2. The ISP for resident 5, dated 12/13/2019, indicates that the resident needs to be spoon-fed; however, the ISP also states that this will be performed by dietary staff, not direct care staff. 3. The uniform assessment instrument (UAI) dated 9/1/2019 in the record for resident 13 has documentation that the resident requires supervision with eating and feeding. The ISP dated 9/1/2019 is incorrect as it has that only dietary staff are supervising and cueing the resident at meals but interviews with staff 11 indicated that this service is provided by direct care staff.
Plan of Correction:	Resident #3, Resident #5, and Resident #13 ISPs were reviewed and updated as indicated prior to end of day, HWD/designee will review 25% of resident UAI/ISP quarterly. ISP to capture daily life based on resident centered care. ISP to be completed with resident, family members, and additional health care providers to address the care and services are that are provided per resident choice, current capabilities, capturing independence, daily routines, preferred social engagement, how they identify with themselves, and provides sense of purpose. ISP to reflect the person and provide team members with the tools to provide resident-centered care.
Standard #:	22VAC40-73-640-A
Description:	640-A Based on observations of the facility medication carts, the facility failed to implement their medication management policy in regards to methods to prevent the use of outdated medications. EVIDENCE: 1. An opened Humalog Flex Pen was observed in the medication cart for resident 11. The pen was not labeled with an open date to ensure disposal of within 28 days per manufacturer?s instructions. The facility medication management plan has documentation that an open date is to be placed on any multi-dose containers when opened.
Plan of Correction:	Resident #11 Insulin Pen was labeled with an open date. An audit of medication requiring an open date or date of expiration for dates. The HWD/designee will audit medication carts monthly for open and expiration dates on required medications. The HWD/designee will re-train nursing staff on medication required medication labeling.
Standard #:	22VAC40-73-680-B
Description:	680-B Based on observations of the facility medication carts, the facility failed to ensure that medications remained in the pharmacy containers with prescription labels attached. EVIDENCE: 1. One white and one pink pill was observed to be loose in the drawers of the Cottage medication cart. 2. A white pill was observed to be loose in the drawer of the Garden medication cart.
Plan of Correction:	LI aware that medication inadvertently came out of bubble packs. ` Med cart drawer was cleaned prior to LI departure. HWD/designee will audit med cart monthly. The nursing team has scheduled cart audits weekly.
Standard #:	22VAC40-73-680-D
Description:	680-D Based on observations made of the morning medication pass, the facility failed to administer medications in accordance with physician instructions. EVIDENCE: 1. The February 2020 medication administration record (MAR) for resident 12 has numerous 9AM medications that were not administered as of 12:20PM on the day of inspection. An interview with staff 2 expressed that when resident 12 is asleep at 9AM the medications are not administered. There are no physician's orders in the resident?s records to hold her 9AM medications if the resident is asleep. 2. The record for resident 9 has a physician order for Seroquel 75mg in the evening for mood. The February 2020 MAR for resident 9 has documentation of Seroquel 50mg being administered in the evenings.
Plan of Correction:	Resident 1 medication was documented as a refusal on eMAR at time of inspection. LI aware that Med Tech had reported to nurse and physician of resident refusal of morning meds. Resident was sleeping or not wanting to take medication because sleepy at time of med pass. Med Tech attempt to re-administer and physician had been notified community needed further direction. HWD/ED or designee will review March POS for medication times and resident daily path routines. If needed and appropriate medication time adjustments to be made to meet resident on their time and assist with medication compliance. HWD or designee will provide re-training to medication administration team members on documentation of medication administration, refused, wasted, counted, opened, date of expiration. Resident 2 Seroquel order was new RX prescribed from the hospital return previous day. Pharmacy had new order with new med pack in route. Medication order clarified and eMAR updated prior to end of LI. HWD/ED or designee will re-train on physician orders, how to file orders within wellness record, proper turnover with shift change information being relevant to resident, med orders Discharge papers to be reviewed by HWD/designee. New orders signed off by HWD/designee. Medication time adjustments to be made if necessary per resident request.
Standard #:	22VAC40-73-720-A
Description:	720-A Based on resident record review, the facility failed to ensure that the written Do Not Resuscitate (DNR) order is included in the individualized service plan (ISP). EVIDENCE: 1. The ISP in the record for resident 5, dated 12/13/19, did not contain the resident?s DNR order.
Plan of Correction:	Resident #5 ISP updated with DNR status. HWD/designee will review resident UAI/ISP for DNR status and update as necessary. HWD/designee will review 10% resident UAI/ISP monthly for DNR status and update as necessary.