Inspection Reports for Brookdale at Home® Midlothian
14016 Turnberry Lane,Midlothian, VA, VA
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Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 1, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-23 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations being issued. Specifically, the facility failed to provide adequate supervision of resident care and activities, leading to a resident sustaining skin tears and being physically harmed by a staff member who subsequently resigned.
Complaint Details
Complaint was substantiated. Evidence showed Resident #1 in the memory care unit sustained skin tears from being grabbed roughly and was also hit by a personal care staff member. The staff member resigned following the incident investigation.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision of resident care and activities, resulting in resident injury due to staff misconduct. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-01 regarding allegations in the area of Admission, Retention and Discharge of residents.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. No violation notice was issued.
Complaint Details
Complaint received on 2025-07-01 regarding Admission, Retention and Discharge. The complaint was not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Jun 4, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on May 1, 2025, regarding allegations related to Resident Care and Related Services at the facility.
Findings
The investigation supported some, but not all, of the allegations. The facility was found non-compliant in areas of Resident Care and Related Services, including failure to update Uniform Assessment Instruments (UAI) after significant changes in resident condition, failure to update individualized service plans (ISP) to reflect assessed needs, and inadequate documentation of staff rounds for residents unable to use signaling devices.
Complaint Details
The complaint was substantiated in part; evidence supported some allegations of non-compliance related to Resident Care and Related Services.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that each Uniform Assessment Instrument (UAI) is completed prior to admission, updated annually, and whenever there is a significant change in a resident's condition. |
| Facility failed to ensure the individualized service plan (ISP) was reviewed and updated to include all assessed needs. |
| Facility failed to ensure that if a resident is unable to use the signaling device or call system, the ISP documents the inability and specifies the minimum frequency of daily rounds by direct care staff, and failed to document rounds made. |
Report Facts
Number of residents present: 29
Number of resident records reviewed: 4
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Feb 24, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-13 regarding allegations in Resident Care and Related Services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. No violation notice was issued.
Complaint Details
Complaint received on 2025-02-13 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 71
Deficiencies: 8
Jan 27, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with several standards related to resident care and staff requirements, resulting in documented violations and a violation notice issued to the facility.
Deficiencies (8)
| Description |
|---|
| Facility failed to perform a review of the continued appropriateness of placement in the special care unit. |
| Facility failed to ensure that each staff person submit annually to a tuberculosis risk assessment. |
| Facility failed to obtain a tuberculosis risk assessment on or within seven days prior to the first day of work for each staff person. |
| Facility failed to maintain current certification in first aid for each direct care staff. |
| Facility did not complete an annual risk assessment for tuberculosis for each resident. |
| Facility failed to complete an annual uniform assessment instrument for all residents. |
| Facility failed to review and update individualized service plans for each resident annually. |
| Facility failed to review the rights and responsibilities of residents annually. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 4
Number of staff interviews: 3
Inspection Report
Renewal
Census: 70
Deficiencies: 4
Jan 10, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found non-compliance with several standards related to resident record reviews, including failure to perform six-month reviews for memory care appropriateness, incomplete annual Uniform Assessment Instruments, lack of preliminary plans of care upon admission, and failure to update individualized service plans annually.
Deficiencies (4)
| Description |
|---|
| Failed to perform a six-month review of the appropriateness of continued residence in the memory care unit. |
| Failed to complete a Uniform Assessment Instrument at least annually and when there is a significant change in resident condition. |
| Failed to develop a preliminary plan of care to address basic needs within or on seven days prior to admission. |
| Failed to review or update individualized service plans once every 12 months. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews with residents: 3
Number of interviews with staff: 3
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Dec 11, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-11-27 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint received on 2023-11-27 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 72
Number of resident records reviewed: 1
Number of interviews with residents: 1
Number of interviews with family: 1
Inspection Report
Monitoring
Census: 78
Deficiencies: 7
Jun 27, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations related to resident records, including failure to follow order of priority for placement in a secure environment, incomplete tuberculosis risk assessments, missing discharge statements, delayed comprehensive service plans, unsigned individualized service plans, and failure to update service plans to reflect Do Not Resuscitate orders.
Deficiencies (7)
| Description |
|---|
| Failed to ensure that the order of priority was followed prior to placement in a secure safe environment. |
| Failed to document the results of a tuberculosis risk assessment. |
| Failed to complete an annual tuberculosis risk assessment on each resident. |
| Failed to retain a written discharge statement in the resident record. |
| Failed to complete comprehensive service plans within 30 days after admission. |
| Failed to have individualized service plans signed and dated by the resident or their legal representative. |
| Failed to ensure that a Do Not Resuscitate Order was included in the Individualized Service Plan for each resident. |
Report Facts
Number of residents present: 78
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 75
Deficiencies: 0
Jun 20, 2022
Visit Reason
The inspection was a monitoring visit to review compliance with various administrative, personnel, resident care, and facility standards.
Findings
The inspection found no violations of applicable standards or laws during the tour of the physical plant, record reviews, interviews, and observations.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Resident interviews conducted: 0
Staff interviews conducted: 2
Inspection Report
Renewal
Census: 62
Deficiencies: 0
Jan 21, 2021
Visit Reason
A renewal inspection was initiated on January 21, 2021 and concluded on March 4, 2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection determined no violations with applicable standards or law. No violations were issued.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
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