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: April 19, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 4/19/2021 and concluded on 4/21/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 32. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	1090-A Based on record review, the facility failed to ensure that prior to admission to a safe, secure environment, the resident shall have been assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: 1. Resident 3 was admitted to the memory care facility (safe, secure unit) on 1/6/2021. The Assessment of Serious Cognitive Impairment (ASCI) for this resident, dated 12/31/2020, indicated that the resident was diagnosed with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia; however, he was able to recognize danger or protect his own safety and welfare. 2. Interview with staff 4 confirmed that the ASCI was correct at the time that resident 3 was admitted to the facility.
Plan of Correction:	The Assessment of Serious Cognitive Impairment for Resident #3 was immediately corrected on April 26, 2021 to reflect resident #3 inability to recognize danger or protect to his own safety and welfare. Executive Director or Designee to provide education on Assessment of Serious Cognitive Impairment to Health and Wellness Director, Health and Wellness Coordinator and Sales Manager by May 7, 2021. Health and Wellness Director or Designee will audit all current resident Assessment of Serious Cognitive Impairment by May 7, 2021. To assist with on-going compliance, the Executive Director, Health and Wellness Director, or Designee will randomly audit resident Assessment of Serious Cognitive Impairment regarding standard 22VAC40-73-1090 once a month for 3 months.