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: Oct. 8, 2024

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/8/24/24 from 8:30 am to 4:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 3 Observations by licensing inspector: 3 Additional Comments/Discussion: Buildings and Grounds An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on the record review the facility did not ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician 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. The record for resident #5, admission date of 6/20/24, did not contain an assessment for serious cognitive impairment. 2. Staff #1 confirmed the record for resident #5 did not contain an assessment for serious cognitive impairment.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-1090-A Assessment ? Facility does not have the ability to retroactively correct missing cognitive impairment assessment on resident number 5 as they are no longer residing at the community. ? The Executive Director or designee will retrain the Sales Manager and the direct care clinical staff regarding the requirements to have the cognitive impairment assessment and other forms completed upon admission. ? The Executive Director, and Sales Manager, or designee will audit 5% of current resident files for compliance by 12/1/2024. ? To assist with ongoing compliance the Executive Director or designee will conduct review of all new resident files monthly for 2 months.
Standard #:	22VAC40-73-1110-A
Description:	Based on the record review the facility did not ensure prior to admitting a resident with a serious cognitive impairment due to a primary diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident?s file. Evidence: 1. Resident?s #3 approval for placement in the special care unit dated 8/31/24 was not signed by the licensee, administrator, or designee and did not include a determination and justification for the decision to place the resident in the special care unit. Resident #3 progress notes document the resident was admitted to the special care unit on 9/23/24. 2. The record for resident #5, admission date of 6/20/24, did not contain a determination and justification for placement in the special care unit completed by the licensee, administrator, or designee. 3. Staff #1 confirmed the record for resident #5 did not contain a determination and justification for placement in the special care unit.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-1110-A Appropriateness of Placement and Continued Residence ? Facility does not have the ability to retroactively correct missing approval for placement in a special care unit on resident number 3 and resident number 5 as they are no longer residing at the community. ? The Executive Director or designee will retrain the Sales Manager and the direct care clinical staff regarding the requirements for placement in a special care unit and forms done upon admission. ? The Executive Director, and Sales Manager or designee will audit 5% of current resident files by 12/1/2024. ? To assist with ongoing compliance the Executive Director or designee will conduct review of all new resident files monthly for 2 months.
Standard #:	22VAC40-73-50-A
Description:	Based on the onsite record review the facility did not ensure to provide a statement to the prospective resident and the prospective resident?s legal representative, if any, that discloses information about the facility. The statement shall be on a form developed by the department and shall include information as listed in this subsection. Evidence: 1. The record for Resident #3, did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their resident?s record. 2. Staff #1 confirmed the record for resident #3 did not contain a disclosure statement.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 11/1/2024. 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. 22VAC40-73-50-A Disclosure ? Unable to retroactively correct signed disclosure upon admission for resident number 3. ? Executive Director or designee will retrain the Sales Manager and direct care clinical staff members regarding the requirement to have a signed disclosure statement on every resident prior to or upon admission to the facility. ? The Executive Director, Health and Wellness Director or Designee will conduct an audit of 5% of current resident records to verify completion of a disclosure statement by 12/1/2024. ? To assist with on-going compliance, the Executive Director, Sales Manager, Resident Care Coordinator, Health and Wellness Director or Designee will review all new resident?s records for completion of a disclosure statement at admission monthly for 2 months.
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility did not ensure to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for resident #1, admission date of 7/01/21, contains a risk assessment for TB dated 2/11/23. The resident?s record does not contain an annual risk assessment for TB completed after 2/11/23. 2. Staff #1 confirmed the record for resident #1 did not contain an annual risk assessment for TB completed after the date of 2/11/23.
Plan of Correction:	The following is the plan of correction for Brookdale Virginia Beach regarding the Statement of Deficiencies dated 11/1/24. 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. 22VAC40-73-320-B Physical examination and report-Subsequent tuberculosis evaluations ? Facility is unable to retroactively correct tuberculosis evaluation for resident number 1 because resident is no longer at the community. ? Executive Director or designee will retrain the Health and Wellness Director, Health and Wellness Coordinator, and Resident Care Coordinator regarding completion of the annual resident tuberculosis risk assessments by 12/1/2024. ? Newly hired Health and Wellness Director will be trained on the annual completion of all resident tuberculosis risk assessments by 12/1/2024. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator, or Designee will conduct an audit of 5% of current resident tuberculosis risk assessments for compliance utilizing Point Click Care scheduled form by 12/1/2024. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director or Designee will conduct review of all current resident tuberculosis risk assessments monthly for 2 months.
Standard #:	22VAC40-73-325-B
Description:	Based on the record review the facility did not ensure the fall risk rating shall be reviewed and updated after a fall. Evidence: 1. The record for resident #1 contains a progress note dated 9/26/24 and an emergency room visit note dated 9/26/24 documenting the resident experienced a fall on 9/26/24. Resident?s #1 record did not contain a fall risk rating after the resident?s fall that occurred on 9/26/24. 2. Staff #1 confirmed the record for resident #1 did not contain documentation of a fall risk rating completed after 9/26/24. 3. The record for resident #5 contains progress notes that documents on the following dates the resident experienced a fall: 6/23/24, 6/26/24, 7/02/24, 07/08/24, 07/09/24. Resident?s #5 record did not contain documentation of a fall risk rating completed after each fall. 4. Staff #1 confirmed the record for resident #5 did not contain documentation of a fall risk rating completed after the following dates: 6/23/24, 6/26/24, 7/02/24, 07/08/24, 07/09/24.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-325-B Fall Risk Rating ? Facility cannot retroactively correct record for resident number one, who is no longer a resident of the community. The Executive Director or designee will correct record for resident number five. ? The Executive Director or designee will retrain the direct clinical staff on fall risk prevention procedures, interventions, and safety ratings post fall. ? The Executive Director or designee will audit 5% of the current resident records for compliance by 12/1/2024. ? To assist with ongoing compliance the Executive Director or designee will conduct reviews of all current resident records for fall risk ratings monthly for two months.
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility did not ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record for resident #2, admission date 6/17/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian. 2. The record for resident #4, admission date 10/07/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian. 3. The record for resident #5, admission date 6/20/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-410-A Orientation and related information for residents ? Facility does not have the ability to retroactively correct signed orientation for resident number one as resident is no longer at the community. ? The Executive Director or designee will retrain Sales Manager and Clinical Staff on providing orientation documents upon admission to the facility by 12/1/24. ? The Executive Director, Business Office Manager, or designee will audit 5% of the current resident population to verify completion of orientation documentation in the resident?s records with signatures by 12/1/24. ? To assist with ongoing compliance the Executive Director, Business Office Manager, or designee will conduct reviews of current residents monthly for two months
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility did not ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission. Evidence: 1. The record for resident #5, admission date of 6/20/24, did not contain a UAI. 2. Staff #1 confirmed the record for resident #5 did not contain a UAI. 3. The record for resident #3, admission date of 9/23/24, did not contain a UAI completed prior to admission. The UAI in the record is dated 9/24/24.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-440-A Uniform Assessment Instrument ? Facility does not have the ability to retroactively correct Uniform Assessment Instrument as resident number one (deceased) and resident number two (discharged) are no longer residing in the facility. ? The Executive Director or designee will retrain Sales Manager and Clinical Staff regarding the requirement for a Uniform Assessment Instrument completion prior to admission. ? The Executive Director or designee will audit 5% of the current resident population for completed Uniform Assessment Instruments by 12/1/2024. ? To assist with ongoing compliance the Executive Director or designee will conduct reviews of all new resident records monthly for two months.
Standard #:	22VAC40-73-440-B
Description:	Based on the record review the facility did not ensure for private pay individuals, the UAI shall be completed by one of the following qualified assessors: an assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training. Evidence: 1. Resident?s #1 UAI dated 8/14/24 was not signed by the facility?s administrator or the administrator?s designated representative. 2. Resident?s #2 UAI dated 5/30/24 and 6/17/24 was not signed by the facility?s administrator or the administrator?s designated representative.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-440-B Uniform Assessment Instruments ? Executive Director or designee will correct Uniform Assessment Instrument of Resident number 1 and Resident number 2. The Executive Director, Health and Wellness Director or designee will review and update the Uniform Assessment Instruments with current care needs for resident?s number 1 and 2 by 12/1/2024. ? The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators on completion of the Uniform Assessment Instruments. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit of 5% of current resident records for UAI completion by 12/1/2024. ? To assist with ongoing compliance, the Executive Director, Health and Wellness Director, and Health and Wellness Coordinator or Designee will conduct reviews of all current resident Uniform Assessment Instruments monthly for two months. Uniform Assessment Instruments will be updated for residents during upon admission, annually or a significant change in condition.
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility did not ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #3, admission date of 9/23/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. Resident?s #1 ISP is dated as initiated on 9/26/24 and 9/27/24.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-450-A Individualized Service Plans ? Facility unable to correct Individualized Service Plan on Resident 3 as resident is no longer at the community. Facility able to correct Individualized Service Plan for resident number 1. The Executive Director, Health and Wellness Director or designee will review and update the Individualized Service Plan with current care needs for resident number 1 by 1/1/2025. ? The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators on Individualized Service Plans. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit of 5% of current resident records for compliance by 1/1/2025. ? To assist with ongoing compliance, the Executive Director, Health and Wellness Director, and Health and Wellness Coordinator or Designee will conduct a review of all current resident Individual Service Plans monthly for two months. Individual Service Plans will be updated for residents during admission, annually, and for significant changes in condition.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility did not ensure the ISP shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. The record for resident #3 contains an ISP that includes an initiated date of 9/26/24 and 9/27/24 however the ISP does not include the date the ISP was signed by the licensee, administrator, or his designee. The resident?s ISP did not include the signature of the resident or the legal guardian. 2. Resident?s #5 ISP dated 6/20/24 and 07/09/24 was not signed and dated by the resident or the legal guardian. 3. Resident?s #4 ISP dated 10/07/24 was not signed by the licensee, administrator, or designee and the resident or legal guardian.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-450-E Individualized Service Plans ? Facility unable to retroactively correct Individualized Service Plan on Resident number 3 and Resident number 5 as residents are no longer at the community. ? The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators and any ISP certified associates on Individualized Service Plans. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct an audit of 5% of current resident ISP records by 1/1/2025. ? To assist with ongoing compliance, the Executive Director, Health and Wellness Director, and Health and Wellness Coordinator or Designee will audit all current resident Individual Service Plans monthly for two months. Individual Service Plans will be updated for residents during admission, annually, and for significant changes in condition.
Standard #:	22VAC40-73-680-E
Description:	Based on the record review the facility did not ensure medical procedures or treatment ordered by a physician or other prescribed shall be provided according to his instructions and documents. The documentation shall be maintained in the resident?s record. Evidence: 1. The record for resident #2 contains the following physician orders: a physician order dated 7/31/24 that includes the following instructions: ?(CBC)? complete blood count; a physician order dated 9/04/24 stating the following instructions: ?labs ordered on 7/31/24 need results.? Resident?s #2 record did not contain lab results completed after the dates of 7/31/24 and 9/04/24. 2. Staff #1 confirmed the record for resident #2 did not contain lab results completed after the date of 7/31/24 and 9/04/24. 3. The record for resident #2 contains the following physician order: A physician order dated 8/14/24 that includes the following instructions: ?podiatry eval & treat.? Resident?s #2 record did not contain documentation of a podiatry evaluation and/or treatment. 4. Staff #1 confirmed the record for resident #2 did not contain documentation of completion of a podiatry evaluation and treatment.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/1/2024. 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 improvement to satisfy that objective. 22VAC40-73-680-E Administration of Medications and Related Provisions ? The Executive Director, Health and Wellness Coordinator or designee will correct lab and podiatry orders for resident number 2 by 12/1/2024. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator or designee will retain direct clinical staff on how to input orders from physicians for Lab and podiatry orders. ? To assist with on-going compliance, the Executive Director, Health and Wellness Director and Health and Wellness Coordinator or designee will audit 5% of current resident records for physician?s orders monthly for two (2) months.