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: Aug. 8, 2023

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

Provisions for Signaling and Call Systems

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/08/2023 from 1:05 pm to 3:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 07/27/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can be found on the violation notice. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on the record review and staff interview the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #1 contains a physician note dated 07/13/23 that documents the resident was hospitalized for edema and congestive heart failure. During an interview with staff #1, staff #1 confirmed the resident was admitted to the hospital the dates of 07/04/23-07/12/23 for congestive heart failure. The facility did not notify the regional licensing office of the resident?s hospital admission the dates of 07/04/23-07/12/13. 2. The record for resident #1 contains a progress note dated 07/12/23 that documents the resident was sent to the ER due to a fall and a skin tear to the left arm as a result of the fall. The facility did not notify the regional licensing office of the resident?s ER visit that occurred on 07/12/23.
Plan of Correction:	?The Executive Director, Health & Wellness Director were retrained on major incident reporting by the Executive Director on August 21, 2023 ?The Executive Director, Health & Wellness Director or designee will report to the regional licensing office within twenty-four (24) hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident ?To assist with ongoing compliance, the Executive Director, Health and Wellness Director or Designee will conduct an audit once a month for two months. The audit will verify all residents who have had any major incidents since 8/21/23 have been reported to the regional licensing office within twenty-four (24) hours.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed by the resident or his legal guardian. Evidence: 1.Resident #1?s ISP dated 06/06/23 and 07/13/23 was not signed by the resident or the legal guardian.
Plan of Correction:	?The Executive Director, Health & Wellness Director or designee will request a meeting with a resident and/or their legal representative to review the ISP and obtain a signed ISP from the resident or their legal representative. If the resident?s legal representative is not available for an in-person meeting, the Executive Director or designee will mail the ISP to the resident?s legal representative, The Executive Director or designee will note that the ISP has been mailed, in the resident?s medical record. If the resident or their legal representative provide verbal acknowledgment of the ISP, the acknowledgement will be noted in the resident?s medical record by the Executive Director or designee. ?To assist with ongoing compliance, the Executive Director or Health & Wellness Coordinator or designee will conduct an audit once a month for two months to verify current residents have signatures on ISPs.