VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Staunton
1900 Hillsmere Lane
Staunton, VA 24401
(540) 885-9500

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Dec. 30, 2019

Complaint Related: No

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Discussions occurred on the following topics: 1) Newly hired staff are to have 10 hours of dementia training completed within the first four months of hire date. 2) Ensure all insulin orders contain parameters. 3) Review of MAR and PRN frequency as it relates to resident A. 4) Replacement of Assessment of Serious Cognitive Impairment to be on file for resident F.

Comments:

The information contained in this renewal inspection will be reviewed by the licensing administrator and the facility will be notified by mail of license status. A renewal inspection was completed by two LIs on 12/30/19. There were a total of 101 residents in care. The facility was clean and free from any foul odors. The outside postings were current as were related drills. The activity calendar and lunch menu accurately reflected what the LIs observed. Ten resident, one discharge and five staff records were reviewed. The December medication administration records were reviewed for a selected number of residents. There were three violations during this renewal inspection. Details of non-compliance can be viewed in the violation report of this inspection. If you have any questions, please contact the licensing inspector at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based upon review of residents' records, the facility failed to ensure documentation for determination and justification of placement in a secure environment is retained in resident's file. EVIDENCE: There is no documentation of appropriateness of placement on file for residents I, J, K, L, M, N and O.
Plan of Correction:	?Resident I, J, and O was assessed and documentation of appropriateness of placement was completed and is on file. Residents K, L, M, and N do not reside in the memory care unit. ?The HWD/designee will re-educate staff regarding required documentation for determination and justification of placement in a secure environment and how to be retained in residents file by January 17, 2020. ?The HWD/designee will conduct an audit of all residents? files in the secured unit no later than January 17, 2020 to verify all residents have documentation of appropriateness of placement completed and on file. ?In order to maintain ongoing compliance the HWD/designee will review residents? charts in the Secured Unit monthly to verify all documentation requirements are met.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of residents' records, the facility failed to ensure the Individualized Service Plan (ISP) includes all required information. EVIDENCE: 1) The Uniform Assessment Instrument (UAI) for resident D indicates physical assistance is needed with wheeling. This is not reflected on the ISP. a. The special diet ordered for resident D is not on the ISP. 2) The ISP for resident F does not include signature of the legal representative. 3) The UAI for resident H indicates assistance is needed with wheeling. This is not reflected on the ISP. a. The UAI indicates mechanical assistance is needed with walking. The ISP indicates walking is not performed. b. The UAI indicates mechanical assistance is needed with transferring. The ISP indicates physical assistance only. 4) The ISP for resident J does not include signature of person completing the plan or signature of legal representative. a. The description of allergic reaction to bee stings is not included on the ISP. 5) The ISP for resident L indicates resident is a DNR status. Full code status is indicated on resident's chart. a. The ISP indicates resident is independent with dressing. The UAI indicates resident needs supervision. 6) The ISP for resident M does not indicate resident has bi-lateral hearing loss and physician visits every 6 months. a. The UAI indicates resident has some disorientation. The ISP indicates resident is oriented. 7) The ISP and chart for resident N indicates full code status. The file contains a DNR effective 07/01/16. a. The UAI indicates resident is confused and forgetful with moderate dementia. The UAI indicates resident is oriented. b. The allergies indicated on the ISP for resident N do not match the physical on file. c. The UAI indicates resident is independent with bathing and toileting. The ISP indicates mechanical assistance is needed. 8) The ISP for resident O does not include signature of person completing plan or signature of legal representative. 9) The ISPs reviewed for residents do not indicate whether the resident was offered and received a copy of the plan as indicated on the ISP.
Plan of Correction:	?The Individual Service Plan (ISP) for residents D, F, H, J, L, M, N, and O have been updated to reflect assessed needs for mechanical and/or physical assistance to coincide with the accuracy of the Uniform Assessment Instrument (UAI) and in the process of reviewing with families and resident to obtain signatures. ?Re-training for staff certified to complete ISPs and UAI?s will be conducted by the Health and Wellness Director (HWD)/designee no later than January 17th, 2020 to verify understanding of accuracy of assessments for the ISPs and the UAIs. ?The HWD/designee will conduct an audit of current residents ISP?s and UAI?s no later than January 17th 2020 to verify the ISPs and UAIs are accurate. ?To assist with ongoing compliance, the ISPs and UAIs will be reviewed on a random basis upon new admissions, re-admissions and residents with changes in condition on a weekly basis for 4 weeks and then on a monthly basis thereafter for 6 months by the HWD/designee.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' records, the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1) Resident B has the following order: Check blood glucose twice a day. Fax values to MD in one week. If below 60 or above 400, notify physician. a. Documentation in the electronic Medication Administration Record (MAR) indicates resident's blood glucose was 466 on 12/21/19 at 4:00pm. There is no documentation of physician notification in the electronic MAR. 2) Resident C has the following order: PRN Oxygen at 2 liters per minute via nasal cannula and/or tank every hour as needed for O2 saturation less than 90% or shortness of breath. a. There is no documentation of O2 saturation monitoring. 3) Resident C has the following order: Humalog 100 Unit/ml: Inject subcutaneously per sliding scale: If blood glucose is 200-250=2 units; 251-300=4 units; 301-350=6 units; 351+=8 units. Call MD after 2 sequential checks if blood glucose is greater than 350. a. Documentation in the MAR indicates resident's blood glucose was 406 on 12/16/19 at 4:00pm. b. There is no documentation of sequential blood glucose check and physician notification. 4) Resident D has PRN orders for Calmoseptine and Albuterol. The orders do not include the time frame to notify the physician or hospice. 5) Resident E has a PRN order for Lorazepam that does not include instructions as to what to do if symptoms persist.
Plan of Correction:	?Resident B Blood Sugars have been faxed for physician review waiting on return response for any possible order changes. Resident C oxygen order was clarified resident uses oxygen PRN for shortness of breath. Resident C Blood Sugars have been faxed for physician review waiting on return response for any possible order changes. Resident D PRN orders for Calmoseptine and Albuterol have been clarified regarding the time frame to notify the physician and hospice if medications are not effective. Resident E, PRN order was clarified with instruction for her lorazepam if symptoms persist. ?Re-training for staff nurses and Medication Aides will be completed by the HWD/designee no later than January 17, 2020, in regards to complete PRN orders and what to do if symptoms persist. In addition education will be completed on notification of physician when ranges are outside of normal parameters. ?A daily review of the Medication Administration Records will be conducted by the HWD/designee times 4 weeks to maintain that documentation and medication administration is conducted per the Virginia regulations. ?An audit of current PRN orders will be completed and clarified no later than January 10th to verify directions for what to do if symptoms persist. ?To assist with ongoing compliance, PRN orders will be reviewed by the HWD/designee for what to do if symptoms persist on a daily basis per the ?New Order Tracking? and Medication Administration Program. In order to maintain ongoing compliance the HWD / designee will review Medication Administration records and medication orders with parameters to make sure physician notification has occurred ongoing times 6 months.