VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: June 1, 2020 , June 3, 2020 , June 4, 2020 , June 5, 2020 and June 8, 2020

Complaint Related: Yes

Areas Reviewed:

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

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 complaint inspection was initiated on 06-01-2020 and concluded on 06-08-2020. A complaint was received by the department regarding allegations in the areas of Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-390-C
Complaint related:	Yes
Description:	Based on resident record review and interview, the facility failed to ensure the original resident agreement/acknowledgment was updated whenever there are changes to any of the policies or information referenced or identified in the agreement/acknowledgment and dated and signed by the licensee or administrator and the resident or his legal representative. Evidence: 1. Resident #1 admitted to the facility on 04-10-2020. The ?Residency Agreement? dated 04-09-2020 (signed by resident #1?s legal representative on 04-10-2020 did not include documentation of the requirements for companion services upon admission or the ?Addendum to the Residency Agreement Isolation Requirements.? 2. The staff ?Progress Notes? for resident #1 documented: A. On 04-10-2020, ?Resident will remain on isolation per facility protocol for 14 days 24/7 with companion/family.? B. On 04-11-2020, ?Resident currently quarantined in his room with a personal sitter.? C. On 04-12-2020, ?? had a sitter thru the night?? 3. On 06-04-2020, staff #1 stated ?? we require only companion services during the isolation period...? Staff #1 provided a copy of an ?Addendum to the Residency Agreement Isolation Requirements? dated 04-17-2020. The addendum documented ?? Requirement for Isolation. Due to the COVID-19 pandemic, new residents must remain in isolation in their Suite for fourteen (14) days upon moving into the Community (?Isolation Period?). Requirement for Companion. Resident needs assisted isolation due to dementia, requiring a companion throughout the Isolation Period?.? 4. During interview, staff #1 acknowledged resident #1?s ?Residency Agreement? was not updated to include the ?Addendum to the Residency Agreement Isolation Requirements."
Plan of Correction:	? Unable to retroactively correct initial resident agreement for resident #1. Initial resident agreement contains acknowledgement for companion/sitter services which POA acknowledged and signed. Updated addendum immediately reviewed with and signed by POA and initiated. ? The Executive Director or Designee will provide education for the Business Office Coordinator and the Sales Manager on resident agreements and addendums and the Virginia regulations to be completed by 7/1/2020. ? The Business Office Coordinator or Designee will audit current resident agreements to be completed by 7/31/2020. ? The Business Office Coordinator or Designee will randomly audit current resident agreements for compliance with Virginia regulations once a month for three months.
Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure all fixtures and equipment are in good repair. Evidence: 1. Staff #1 stated when a resident pulls the call bell cord, the alert will be heard on the staffs? paging device. 2. On 06-03-2020 at approximately 3:05 PM, during a virtual tour of the facility with staff #1, the following fixtures and equipment observed were not in good repair: A. The call bells did not work when the cord was pulled by staff #1 in room #11, (bed A call bell) and room #21, (call bell located in the bathroom). B. Staff #1 attempted to pull the cords on the aforementioned call bells approximately two times, however, the paging device held by staff #1 did not transmit a signal for assistance. C. One of the sides of the toilet paper holder was broken on the wall in the community shower located in the ?Military Hallway.? 3. Staff #1 acknowledged the aforementioned call beds and the toilet paper holder were not in good repair.
Plan of Correction:	? Repair made to signaling system for apartment 11 and 21. Repair made to toilet paper holder in community shower bathroom. ? The Executive Director or Designee will provide education for the housekeeping staff and caregiver staff on reporting maintenance and grounds repairs needed and the Virginia regulations to be completed by 7/15/2020. ? The Maintenance staff or designee and care staff will make apartment checks and facility checks for signaling devices and toilet paper holder for good repair completed by 7/15/2020. ? The Maintenance staff or designee and care staff will randomly audit current resident signaling devices and toilet paper holders for good repair and compliance with Virginia regulations once a month for three months.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to make and document rounds no less than every two hours for each resident with an inability to use the signaling devices, once the resident has gone to bed each evening until the resident has arisen each morning. Evidence: 1. On 06-02-2020, staff #1 provided a copy of resident #1?s current Individualized Service Plan (ISP) dated 04-08-2020 which documented ?resident is unable to use his call bell to alert staff of an emergency need. Direct Care Staff will continue to perform hourly rounds?? 2. Staff #1 provided documentation of the facility?s May 2020 two-hour rounds, which was labeled ?VA Night Check and Special Surveillance Record.? The staff initialed the May 2020 ?VA Night Check and Special Surveillance Record? forms documenting resident #1?s ?Time of check? for two hour rounds was at ?9:10 pm, 11:10pm, 1:10 AM, 3:10 AM, and 5:10 AM? on 05-01-2020 through 05-31-2020. The forms did not include documentation of hourly rounds being completed by staff every hour for resident #1. 3. Staff #1 stated she could not provide two hour rounds for April 2020 or additional documentation verifying hourly rounds were made by direct care staff for resident #1 every hour on 04-10-2020 through 05-31-2020. 4. Staff #1 acknowledged the direct care staff did not make hourly rounds as documented per the ISP.
Plan of Correction:	? Review and update resident #1 ISP for correct two-hour night checks and surveillance. Provide resident with appropriate two-hour nights checks and surveillance. ? The Health and Wellness Director or designee will provide education for the direct care staff on Virginia two-hour night checks and appropriate documentation and the Virginia regulations to be completed by 7/15/2020. ? The Health and Wellness Director or designee will audit the current residents Virginia two-hour night checks and surveillance documentation to be completed by 7/31/2020. ? The Health and Wellness Director or designee will randomly audit current resident Virginia two-hour night checks and surveillance documentation for compliance with Virginia regulations once a month for three months.