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: March 29, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

750-B

Comments:

The LI for Brookdale Roanoke, along with an additional LI, conducted an unannounced renewal study on 03/29/2022 from 8:45 AM until 4:00 PM, finding 38 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, a review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and craft activity. Eight resident records were thoroughly reviewed, and an additional four were partially reviewed in relation to the observation of the medication pass, special diets, or other services received. 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 facility Administrator, Health and Wellness Coordinator, and Business Office Manager 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. 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. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-325-B
Description:	325-B Based on record review, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall. EVIDENCE: Progress notes and the ISP, dated 10/27/2021, were updated to indicate that resident 4 had fallen on 02/01/2022, 03/08/2022, and 03/28/2022; however, the most recent fall risk rating was dated 01/11/2022.
Plan of Correction:	The fall risk rating for resident 4 has been updated. The fall risk score and interventions have been added to the ISP. HWD/ED or designee will complete an audit of charts of residents with falls in the last 6 months for fall risk rating updates and interventions added to the ISP. HWD/ED or designee will provide re-training to staff on fall interventions and post-fall communication with HWD/ED or designee.
Standard #:	22VAC40-73-440-D
Description:	440-D Based on record review and staff interview, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required. EVIDENCE: The UAI for resident 7, dated 01/21/2022, indicated that the resident does not need assistance with eating; however, the resident?s individualized service plan (ISP), dated 01/22/2022, indicated that the resident needs supervision with eating. Interview with staff 5 indicated that the UAI is incorrect and the ISP is correct.
Plan of Correction:	UAI for resident 7 has been corrected to agree with the ISP. HWD/ED or designee will complete an audit of all ISPs/UAIs to verify accuracy and congruency.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) were completed as required. EVIDENCE: 1. The ISP for resident 5, with a review date of 02/10/2022, indicated that the resident is receiving physical therapy services; however, there was no description of services that are being provided by the rehabilitation agency. 2. The uniform assessment instrument (UAI) for resident 6, dated 09/05/2021, indicated that the resident is continent of bowel; however, the ISP for the resident, dated 03/05/2022, indicated that the resident is incontinent of bowel and does wear incontinence supplies. Interview with staff 5 confirmed that the UAI was correct and the ISP was incorrect. 3. The UAI for resident 8, dated 03/14/2022, indicated that the resident needs mechanical help and human supervision with transferring; however, the ISP for the resident, dated 03/14/2022, indicated that the resident needs mechanical help only with transferring. Interview with staff 5 confirmed that the UAI was correct and the ISP was incorrect. 4. On the date of inspection, one licensing inspector (LI) observed in resident 9?s room that there were two Halo Safety Rings on the resident?s bed. The ISP for the resident, dated 11/26/2021, did not indicate that these devices were being used on the resident?s bed nor did it indicate the purpose for use.
Plan of Correction:	Additional description of the physical therapy services which resident 5 is receiving has been added to the ISP for resident 5. ISP for resident 6 has been corrected to agree with the UAI. ISP for resident 8 has been corrected to agree with the UAI. ISP for resident 9 has been updated to reflect the purpose and use of the halo safety ring. HWD/ED or designee will complete an audit of ISPs/UAIs to verify accuracy and congruency
Standard #:	22VAC40-73-450-E
Description:	450-E Based on record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. EVIDENCE: 1. The ISPs for resident 2, dated 12/09/2021, for resident 5, dated 10/12/2021, resident 7, dated 01/22/2022, and resident 9, dated 11/26/2021, did not contain a signature by the resident or legal representative.
Plan of Correction:	ISPs for residents 2, 5, 7, and 9 have been sent electronically to each responsible individual respectively. HWD/ED or designee will complete an audit of ISPs to monitor compliance. If the responsible individual is unable to physically come to the community to sign, the responsible individual may provide acknowledgment of review and acceptance by electronic means. HWD/ED or designee will document attempts made to obtain signature from the responsible individual to show that effort is being made to comply with the regulation.
Standard #:	22VAC40-73-610-D
Description:	610-D Based on record review, staff interview, and observation during tour of the physical plant, the facility failed to ensure that diets prescribed for residents by a physician or other prescriber were prepared and served according to the physician?s or other prescriber?s orders. EVIDENCE: 1. At approximately 8:59 AM on the date of inspection, collateral 1 observed that the special diet list in the kitchen indicated that resident 9 receives a mechanical soft diet; however, the record for resident 9 included a physician?s order, dated 02/16/2022, that the resident is prescribed a pureed diet. 2. Interview with staff 7 indicated that the resident has been receiving a mechanical soft diet and that he was not aware of the physician?s order dated 02/16/2022 for the resident to be served a pureed diet.
Plan of Correction:	The following is the plan of correction for Brookdale Roanoke VA regarding the Statement of Deficiencies dated 3/29/2022. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to the delivery of quality health care services and will continue to make changes and improvements to satisfy that objective. The diet list in the kitchen has been updated to reflect the current physician's diet order for resident 9. DSM/ED or designee will complete an audit of the diet list to verify that all physician-prescribed diets are accurately recorded. DSM/ED or designee will complete an audit of the diet list and physician diet orders every month for 6 months to monitor compliance. The ED will be responsible for directing additional corrective action based on audit findings.
Standard #:	22VAC40-73-640-A
Description:	640-A Based on record review, the facility failed to implement its written plan for medication management, specifically regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s Medication Management Plan, issued 10/2018, states ?All medications maintained within the community that fall under the DEA?s schedules of II ? V? Will be counted by a licensed nurse/RMA from the off going shift and one from the oncoming shift. This procedure will occur at the beginning of each shift or whenever a change is made within that shift. Both staff?s signature and the count of bingo cards and sheets will be documented on either the Schedule II count sheet provided by the communities preferred pharmacy and the communities controlled Medication Inventory sheet.? 2. During the facility?s medication cart audit on the date of inspection at approximately 9:18 AM and 9:27 AM, LI and staff 1 reviewed the Controlled Substance/MAR Change of Shift Audit forms for the three medication carts. As a result, LI observed that the Controlled Substance/MAR Change of Shift Audit form for cart 1 was not completed by the 3 ? 11 PM staff member on 03/01/2022 and 03/02/2022. In addition, the Controlled Substance/MAR Change of Shift Audit form for cart 2 was not completed by the 3 ? 11 PM staff member on 03/19/2022.
Plan of Correction:	HWD or designee will provide re-training to medication administration team on the requirement to complete the Controlled Substance/MAR Change of Shift Audit form checking accurate counts of all controlled substances. HWD/ED or designee will complete an audit of the Controlled Substance/MAR Change of Shift Audit form weekly for 8 weeks to monitor compliance. The ED will be responsible for directing additional corrective action based on audit findings
Standard #:	22VAC40-73-680-H
Description:	680-H Based on observation during a medication cart audit and record review, at the time a medication was administered, the facility failed to document on a medication administration record (MAR) all medications administered to residents. EVIDENCE: 1. The record for resident 6 contained a physician?s order, dated 03/13/2022, for Loperamide 2MG tablet to take two tabs PO after first loose stool, then one tab after each subsequent loose stool PRN for diarrhea. 2. During a medication cart audit, LI observed that the blister pack for this medication was missing one tablet; however, it was not documented on the resident?s March 2022 MAR that this medication had been administered to the resident.
Plan of Correction:	The physician's order for resident 6 was verified and has been transcribed into the MAR. HWD or designee will provide retraining to the medication administration team on proper procedure and documentation for administering medications. HWD/ED or designee will complete an audit of the MAR weekly for 8 weeks to monitor compliance. The ED will be responsible for directing additional corrective action based on audit findings.
Standard #:	22VAC40-73-870-A
Description:	870-A Based on observation during the tour of the physical plant, the facility failed to ensure that the interior of the building was maintained in good repair. EVIDENCE: 1. Collateral 1 observed the flooring of the threshold of room 2 between the living area and bathroom was noted to be peeling away from the base flooring. 2. Collateral 1 observed a long, black mark in front of the heating/cooling unit and behind the resident?s bed located in room 9. 3. The dining room located in the country house section of the facility contained multiple sections of base board and quarter round molding that were observed to have black markings and sections of the white paint missing from them.
Plan of Correction:	A transition strip has been added over top of the flooring of the threshold of room 2 between the living area and bathroom. The flooring in room 9 has been scrubbed and the black markings has been removed. The black markings have been removed from the base boards and quarter round molding in the Country Lane dining room and a fresh coat of paint has been applied.
Standard #:	22VAC40-73-980-B
Description:	980-B Based on observation, the facility failed to ensure that the first aid kit located in the facility?s motor vehicle that is used to transport residents was complete and did not contain items with expiration dates. EVIDENCE: The first aid kit that was located in the facility?s van that is used to transport residents, contained a bottle of Purell hand sanitizer with an expiration date of 10/2020 and multiple Benzalkonium Chloride towelettes that all contained an expiration date of 11/2020. Also, the thermometer located inside the first aid kit was not operable; this was also verified by staff 6.
Plan of Correction:	The expired Purell hand sanitizer and Benzalkonium Chloride towelettes have been removed from the first aid kit. The inoperable thermometer has been replaced with a new one. ED or designee will complete an audit of the van first aid kit to verify that it does not contain items that have passed expiration dates.