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: Nov. 25, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	No
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 documenting the resident experienced a fall on 11/10/24. Resident #1?s record contain a fall risk rating dated 8/28/24 and was not updated after the resident?s fall that occurred on 11/10/24. 2. Staff #1 confirmed the record for resident #1 did not contain documentation of a fall risk rating completed after 11/10/24.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/25/2024 but received on 12/02/2024. 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 ? Unable to retroactively correct Fall Risk ratings for resident number 1 for 11/10/2024. ? The Executive Director or designee will update the Fall Risk ratings for resident number 1 no later than 12/11/2024. ? The Executive Director or designee will provide re-education to the licensed nurses and RMA?s on Fall Risk rating updates no later than 12/11/2024. ? To assist with going compliance, the Executive Director or designee will randomly audit 5 % of current residents with falls for updated Fall Risk ratings once a month for two months. Compliance by 02/11/2025
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on observation and a review of the facility?s Medication Administration Record, it was determined that the facility did not ensure that the MAR shall include Any medication errors or omissions. Evidence: 1. During the Medication Administration Record review for Resident #1, on 11/21/24 the following medications were not signed for: Melatonin 3mg(8:00pm), Trazadone 50mg(8:00pm), Seroquel 50mg(8:00pm), Zoloft 50mg(8:00pm) 2. During the Medication Administration Record review for Resident #2, on 11/21/24 the following medications were not signed for: Atorvastatin 20mg(8:00pm) Trazadone 150mg(8:00pm), Risperidone 0.5mg(8:00pm), Safety checks for 2000, 2200 not documented on 11/21/24. 3. Staff #2 confirmed the medication for resident #1 and Resident #2 were not signed by the staff administering medications.
Plan of Correction:	The following is the Plan of Correction for Brookdale Virginia Beach, Virginia regarding the Statement of Deficiencies dated 11/25/2024 but received on 12/02/2024. 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-I. 11 Administration of Medications and Related Provisions ? Unable to retroactively correct previous medication administration signatures within the ordered period for residents 1 and 2 for date 11/21/2024. ? The Executive Director or designee will provide re-education to LPN?s and RMA?s on medication administration and the need for medications to be signed for within the ordered time frame that said medication is due by 12/13/2024. ? To assist with on-going compliance, The Executive Director or designee will conduct weekly audits for medication administration signatures for 4 weeks and then monthly for two months. Compliance Date: 02/28/2025