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: Jan. 22, 2024

Complaint Related: Yes

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint 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 01/22/24 from 11:25 am to 1:37 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/02/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation and review of the medication cart was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations, area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violations not related to the complaint but identified during the course of the investigation can also 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 #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on the record review the facility failed to implement a written plan for medication management to include: Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. The facility?s medication management plan dated 10/2018 includes the following: ?All medication maintained within the community that fall under the DEA?s scheduled of II-V will be counted by a licensed nurse/RMA from the off going shift and one from the oncoming shift, both staff?s signature and the count of bingo cards and sheets will be documented on the Schedule II count sheet provided by the communities preferred pharmacy and the communities controlled Medication Inventory Sheet.? 2. The facility?s Controlled Substance/MAR Change of Shift Audit Form for Dec. 2023 and Jan. 2024 did not include staff signatures for both the off going and oncoming shifts for the following dates and shifts: 12/10/23, 12/12/23: 7-3 shift 12/14/23, 12/15/23: 3-11 shift 12/20/23: 7-3 shift 12/27/23: 11-7 shift 12/28/23-12/20/23: 11-7, 7-3, and 3-11 shifts 01/01/24: 7-3, and 3-11 shifts 01/02/24: 3-11 shift 01/03/24-01/21/24: 7-3, 3-11, and 11-7 shifts.
Plan of Correction:	On January 23, 2024, the Health &Wellness Director (HWD) provided a re-in-service to the Licensed Practical Nurses (LPNs) and Registered Medication Aides (RMAs) reviewing the process of signing on and signing off on the controlled substance sheets to attest and verify that the controlled substance count is accurate. The HWD will provide another re-in-service of the same topic at our staff meeting on February 29, 2024. To assist with ongoing compliance, the HWD, Health & Wellness Coordinator (HWC) or designee will review the controlled substance book daily to verify the staff are signing on and off that they are counting controlled substances and that the count is accurate for two (2) months. The Executive Director (ED) or designee will perform an audit of the controlled substance book to verify that the LPNs and RMAs are signing each shift monthly for two (2) months.
Standard #:	22VAC40-73-680-M
Complaint related:	Yes
Description:	Based on the onsite observation, and staff interview the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. Resident?s #1 physician orders dated 11/16/22, 11/22/23, and the Jan. 2024 medication administration record (MAR) includes the following PRN Orders: Acetaminophen 500mg, give 2 tablets every 8 hours as needed for pain; Haloperidol Lactate Oral, give 0.5 ml every 6 hours as needed for anxiety/agitation; Loperamide 2mg, give 2 mg by mouth as needed for diarrhea. During observation and review of the medication cart w/staff #1, residents #1 PRN medications to include acetaminophen, haloperidol, and Loperamide was not located on the medication cart. 2. Staff #1 confirmed the following PRN medications ordered for resident #1 was not located on the medication cart and/or located and stored at the facility: Acetaminophen, Haloperidol, and Loperamide.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated February 16, 2024. 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 HWD ordered resident #1?s Acetaminophen, Haloperidol and Loperamide on Jan 23, 2024. The HWD will conduct an audit on all residents? medications on the medication cart and the physician orders to verify all medications ordered are on the cart. The HWD, HWC or designee will verify cart audits are being completed weekly per Brookdale policy for the next two (2) months. To assist with ongoing compliance, the ED or designee will complete random audits of the medication cart to verify PRN medication are on the medication cart monthly for two (2) months.