Inspection Reports for Brookdale Staunton
1900 Hillsmere Lane,Staunton, VA, VA
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Inspection Report
Monitoring
Census: 96
Deficiencies: 3
Dec 11, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with several standards including improper storage of chemicals, incomplete fire and emergency evacuation plans, and incomplete documentation of fire drills. Violation notices were issued with plans of correction required.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure chemicals and other hazardous materials are stored in a locked area. |
| Facility failed to ensure that the fire and emergency evacuation plan includes all required information. |
| Facility failed to ensure that fire drills are completed in accordance with the Virginia Statewide Fire Prevention Code. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Fire drills documented: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gale | Licensing Inspector | Contact person for questions about the inspection |
| Angela N Via | Licensing Inspector | Inspector who conducted the inspection |
Inspection Report
Renewal
Census: 91
Deficiencies: 0
Dec 18, 2023
Visit Reason
The inspection was conducted as a renewal inspection to review the facility's compliance with licensing requirements.
Findings
The Licensing Inspector reviewed multiple areas including administration, personnel, resident care, emergency preparedness, and safety. The inspector observed residents during activities and meals, reviewed records and reports, and found no complaint-related issues.
Report Facts
Records reviewed: 10
Interviews conducted: 9
Inspection Report
Renewal
Census: 96
Deficiencies: 0
Dec 14, 2022
Visit Reason
The inspection was a renewal visit to assess compliance with licensing requirements and regulations for the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The facility was clean, odor free, and compliant with required postings and outside inspections. Residents were observed participating in activities and meals.
Report Facts
Resident records reviewed: 9
Staff records reviewed: 6
Resident interviews conducted: 2
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 83
Deficiencies: 1
Feb 9, 2022
Visit Reason
A monitoring inspection was initiated and concluded on February 9, 2022, to review compliance with regulations for an assisted living facility.
Findings
The facility was found to be clean and free from foul odors with current outside postings and related drills. One violation was identified related to the assessment of serious cognitive impairment documentation for a resident.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure prior to admission to a safe, secured environment, the documented assessment by an independent clinical psychologist or physician indicated the resident had a serious cognitive impairment due to dementia with inability to recognize danger or protect safety. |
Report Facts
Residents in care: 83
Records reviewed: 12
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 22, 2021
Visit Reason
A non-mandated self-report inspection was initiated following a self-reported incident regarding allegations in the areas of resident care. The investigation was conducted by the Health and Wellness Director via telephone.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in a violation for medication administration error where one resident received another resident's medications.
Complaint Details
The visit was complaint-related but the complaint was self-reported by the facility. The evidence supported the self-report of non-compliance and a violation was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure one of two residents' medications were administered as ordered by the physician and in accordance with medication aide standards. |
Report Facts
Date of incident: Nov 21, 2021
Number of residents involved: 2
Medication administration error date: Nov 22, 2021
Deadline for reeducation: Dec 16, 2021
Observation period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 1, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations related to medication administration.
Findings
The investigation found non-compliance with standards including failure to ensure the Individualized Service Plan was properly signed and dated, and failure to administer medications according to physician orders, specifically the administration of discontinued Humulin insulin.
Complaint Details
The visit was complaint-related based on a self-reported incident regarding medication administration. The evidence supported the self-report of non-compliance and violations were issued.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan is signed and dated by the administrator or designee and by the resident or legal representative. |
| Facility failed to ensure medications are administered in accordance with physician's instructions and standards of practice, including administration of discontinued Humulin insulin. |
Report Facts
Units of Humulin insulin administered: 25
Date of Individualized Service Plan: Jun 28, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Inspector | Current inspector conducting the investigation. |
| Health and Wellness Director | Health and Wellness Director (HWD) | Conducted retraining and audits related to ISP and medication administration. |
| Health and Wellness Coordinator | Health and Wellness Coordinator | Conducted in-service on medication administration and reviewed standards of practice. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 6, 2021
Visit Reason
A non-mandated self-report inspection was initiated following a self-reported incident relating to resident care. The investigation was conducted by the Health and Wellness Director and licensing inspector to assess compliance with standards.
Findings
The investigation found non-compliance with standards related to the facility's failure to maintain a comprehensive Individualized Service Plan (ISP) reflecting assessed resident needs, and inadequate monitoring/documentation of a resident with wandering and exit-seeking behaviors. Violations were issued based on these findings.
Complaint Details
The visit was complaint-related, triggered by a self-reported incident involving a resident found walking outside the facility unsupervised. The investigation substantiated non-compliance with care standards.
Deficiencies (2)
| Description |
|---|
| Facility failed to have a comprehensive Individualized Service Plan (ISP) that includes the assessed needs of the resident. |
| Inadequate monitoring and documentation of resident wandering and exit-seeking behaviors, including lack of documentation for frequent checks. |
Report Facts
Inspection Date: Aug 6, 2021
Resident 1 Admission Date: Nov 24, 2019
Resident 1 Discharge Date: Aug 10, 2021
Temperature Range: 64-91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Inspector | Named as current inspector conducting the investigation |
Inspection Report
Renewal
Census: 93
Deficiencies: 0
Nov 23, 2020
Visit Reason
A renewal inspection was initiated on 11/23/20 and concluded on 12/04/20 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection reviewed resident and staff records, staff schedules, fire drills, and outside inspections, and determined no violations with applicable standards or law. No violations were issued.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
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