Inspection Reports for Brookdale Danville Piedmont
149 Executive Court,Danville, VA, VA
Back to Facility Profile
Inspection Report
Monitoring
Census: 45
Deficiencies: 7
Apr 14, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and regulations at the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure direct care staff received timely first aid certification, failure to update individualized service plans with changes in resident conditions, medication management plan deficiencies, improper medication storage and administration, unsecured cleaning supplies, and incomplete fire and emergency evacuation drill documentation.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure direct care staff received certification in first aid within 60 days of employment. |
| Facility failed to ensure individualized service plans were reviewed/updated when a change in resident condition occurred. |
| Facility failed to implement their medication management plan, including expired and improperly dated medications. |
| Facility failed to ensure residents only kept medications in their rooms if capable of self-administration as indicated by assessment. |
| Facility failed to ensure resident medications were administered within one hour before or after the scheduled time. |
| Facility failed to ensure cleaning supplies were stored in a locked area. |
| Facility failed to ensure all required information was included on fire and emergency evacuation drill log sheets. |
Report Facts
Number of residents present: 45
Number of resident records reviewed: 9
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Inspection Report
Renewal
Census: 46
Deficiencies: 4
Dec 12, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with several standards including failure to update individualized service plans (ISPs) after significant resident changes, failure to prepare and serve special diets according to physician orders, failure to follow medication management plans regarding ordering medications, and failure to administer medications within the facility's standard dosing time.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure individualized service plans (ISPs) were updated when a significant change in a resident occurred. |
| Facility failed to ensure that a special diet ordered by a physician was prepared and served according to physician orders. |
| Facility failed to follow their medication management plan in regard to the ordering of medications. |
| Facility failed to ensure that medications were administered not later than one hour after the facility standard dosing time. |
Report Facts
Number of residents present: 46
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Medication administration delay times (minutes): 78
Medication administration delay times (minutes): 78
Medication administration delay times (minutes): 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Jo Ball | Licensing Inspector | Inspector conducting the inspection |
| Health and Wellness Director | Health and Wellness Director (HWD) | Named in plan of correction for reviewing ISPs, retraining staff, and auditing compliance |
| Executive Director | Executive Director (ED) | Named in plan of correction for retraining staff and auditing compliance |
Inspection Report
Renewal
Census: 51
Deficiencies: 12
Nov 15, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable regulations and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including incomplete admission physical examinations, failure to update fall risk ratings after falls, incomplete personal and social information at admission, incomplete uniform assessment instruments, inconsistencies in individualized service plans, medication management deficiencies, missing physician orders, improper medication labeling, unavailable PRN medications, missing 'No Smoking-Oxygen in Use' signage, and maintenance issues such as damage to walls and ceilings.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure a physical examination by an independent physician within 30 days preceding admission with all required components. |
| Facility failed to update fall risk rating for residents after a fall. |
| Facility failed to obtain required personal and social information for residents prior to or at admission. |
| Facility failed to complete the uniform assessment instrument (UAI) as required for private pay individuals. |
| Facility failed to ensure all identified needs were addressed on individualized service plans (ISPs). |
| Facility failed to ensure menus for meals and snacks for the current week were dated and posted conspicuously. |
| Facility failed to implement components of their medication management plan, including expired medications and missing open dates on insulin and eye drops. |
| Facility failed to maintain physician orders in resident records. |
| Facility failed to ensure all medication remained in pharmacy issued container with prescription label until administered. |
| Facility failed to ensure medications ordered for as needed administration (PRN) were available at the facility. |
| Facility failed to post 'No Smoking-Oxygen in Use' signs in rooms where oxygen is in use. |
| Facility failed to maintain the interior of all buildings in good repair, including scratches on walls and ceiling damage. |
Report Facts
Residents present: 51
Resident records reviewed: 13
Staff records reviewed: 4
Resident interviews conducted: 3
Staff interviews conducted: 3
Medication cart audit frequency: 4
Plan of correction review frequency: 4
ISP audit frequency: 3
Inspection Report
Monitoring
Census: 48
Deficiencies: 8
Apr 25, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulatory requirements, including observation of activities, medication administration, record audits, and interviews with residents and staff.
Findings
Multiple deficiencies were identified including unlabeled glucometers in medication carts, incomplete tuberculosis risk assessments for staff, incomplete or unsigned resident physical examinations and individualized service plans, failure to follow procedures for controlled substance counts, missing 'No Smoking-Oxygen in Use' signs in oxygen rooms, and maintenance issues such as cracked drywall columns.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure blood glucose monitoring practices consistent with CDC recommendations; glucometers were not labeled with resident names. |
| Facility failed to ensure tuberculosis risk assessment results were submitted for each staff person on or within seven days prior to first day of work. |
| Facility failed to ensure physical examinations were completed within 30 days preceding admission and contained all required information. |
| Facility failed to ensure individualized service plans (ISP) were signed by the resident or their legal representative. |
| Facility failed to ensure individualized service plans (ISP) were updated to reflect changes in a resident's condition. |
| Facility failed to follow procedures to ensure accurate counts of all controlled substances whenever medication administration staff changes. |
| Facility failed to ensure 'No Smoking-Oxygen in Use' signs were posted in any room where oxygen is in use. |
| Facility failed to maintain the interior in good repair; cracked drywall noted around columns near front door ceiling. |
Report Facts
Residents in care: 48
TB screening completion date: Feb 4, 2021
Resident admission date: Feb 8, 2022
Physical exam date: Aug 5, 2021
ISP update date: Dec 7, 2021
ISP update date: Jan 24, 2022
Controlled substance count missing signatures: 4
Oxygen containers: 8
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 16, 2021
Visit Reason
A self-reported incident prompted an investigation regarding allegations in the areas of resident care and related services at the facility.
Findings
The investigation supported the self-report of non-compliance with standards or law, specifically that the facility failed to ensure resident rights were provided, including abuse or neglect related to staff using a cell phone to record a resident and making threatening statements.
Complaint Details
The visit was complaint-related but the complaint was self-reported by the facility. The evidence gathered supported the self-report of non-compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that resident rights were provided, including abuse or neglect by staff using a cell phone to voice record a resident and making statements about getting the resident kicked out. |
Report Facts
Inspection date: Jul 16, 2021
Inspection Report
Renewal
Census: 50
Deficiencies: 3
Dec 11, 2020
Visit Reason
A renewal inspection was initiated due to the facility's license renewal process and conducted remotely due to a state of emergency health pandemic.
Findings
The inspection found non-compliances with applicable standards, including failures to address all identified needs on individualized service plans (ISPs), incomplete documentation of hospice services on ISPs, and inadequate documentation of accidents and medical attention received by residents.
Deficiencies (3)
| Description |
|---|
| Facility failed to address all identified needs on individualized service plans (ISPs), including diet and wound care needs. |
| Facility failed to ensure that services provided by both the facility and hospice provider are included on the individualized service plan (ISP). |
| Facility failed to document circumstances and medical attention received when a resident suffered an accident, injury, or medical condition, including date, time, and personnel involved. |
Report Facts
Resident records reviewed: 3
Staff records reviewed: 3
Employee schedules reviewed: 1
Fire and health department inspections reviewed: 1
Fire drill logs reviewed: 1
Dietician oversight documents reviewed: 1
ISP audit period: 3
Weekly documentation review period: 4
Loading inspection reports...
