Inspection Reports for Brookdale Virginia Beach
937 Diamond Springs Rd, Virginia Beach, VA 23455, VA, 23455
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Inspection Report
Monitoring
Census: 31
Deficiencies: 0
Nov 14, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-report received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection determined no violations with applicable standards or law. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, as well as conducted interviews with one resident and one staff member.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 31
Deficiencies: 4
Oct 22, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found multiple violations related to staff training in cognitive impairment, annual tuberculosis risk assessments, individualized service plan signatures, and annual resident rights documentation. The facility was given a violation notice and an opportunity to submit a plan of correction.
Deficiencies (4)
| Description |
|---|
| Facility did not ensure that within four months of employment, direct care staff completed at least 10 hours of training in cognitive impairment. |
| Facility did not ensure that each staff person annually submitted a tuberculosis risk assessment documenting they are free of communicable TB. |
| Individualized service plans (ISP) were not signed and dated by the resident's legal guardian or POA. |
| Facility did not ensure that the rights and responsibilities of residents were reviewed and documented annually with the resident or legal representative. |
Report Facts
Number of residents present: 31
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of resident interviews conducted: 4
Number of staff interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 2
May 21, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by VDSS Division of Licensing on 2025-05-08 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance including violations related to freedom of movement for residents and failure to ensure staff made rounds every two hours for residents unable to use signaling devices. Violations were issued based on evidence including APS reports, staff interviews, and record reviews.
Complaint Details
Complaint was substantiated based on evidence including an APS report dated 2025-05-08 and staff interviews confirming residents were blocked from leaving rooms and rounds were not completed as required.
Deficiencies (2)
| Description |
|---|
| Facility did not ensure freedom of movement for residents; residents were locked out of or inside their rooms. |
| Facility did not ensure staff made rounds at least every two hours for residents unable to use signaling devices during nighttime hours. |
Report Facts
Number of residents present: 24
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Number of resident interviews conducted: 0
Audit percentage: 5
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 4
Feb 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation following complaints received by VDSS Division of Licensing on 2025-01-07 and 2025-02-20 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards and violations were issued. Deficiencies included failure to update fall risk ratings after a fall, unsigned individualized service plans, incomplete medication administration records, and failure to complete required resident rounds every two hours.
Complaint Details
The complaint investigation was substantiated with violations issued based on evidence gathered during the inspection.
Deficiencies (4)
| Description |
|---|
| The facility did not ensure the fall risk rating was reviewed and updated after a fall. |
| The individualized service plan (ISP) was not signed and dated by the licensee, administrator, or resident/legal guardian. |
| The medication administration record (MAR) did not indicate whether medication was administered or omitted. |
| Staff did not complete rounds every two hours for residents with inability to use signaling devices as required. |
Report Facts
Number of residents present: 24
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Audit percentage: 5
Plan of correction timeframe: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and is contact for the report |
| Staff #1 | Reviewed records and acknowledged deficiencies during inspection |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Dec 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a self-reported incident received by VDSS Division of Licensing on 12/2/24 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication management, specifically the failure to implement the written plan ensuring accurate counts of controlled substances during staff changes. Violations were issued based on incomplete controlled medication count records.
Complaint Details
The complaint investigation was substantiated as the evidence supported the self-report of non-compliance with medication management standards.
Deficiencies (1)
| Description |
|---|
| Based on the record review the facility did not ensure to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. |
Report Facts
Residents present: 33
Resident records reviewed: 1
Staff interviews conducted: 2
Missing staff signatures: 7
Compliance date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation and named in the report |
| Staff #2 | Confirmed the record for resident #1 and acknowledged the Controlled Medication Count Records were incomplete |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 25, 2024
Visit Reason
The inspection was conducted as a complaint-related investigation to assess compliance with regulations following allegations concerning fall risk rating updates and medication administration documentation.
Findings
The facility failed to update the fall risk rating for a resident after a fall and did not ensure medication administration records included signatures for administered medications on specified dates.
Complaint Details
The visit was complaint-related as indicated. The complaint involved failure to update fall risk ratings after a fall and missing medication administration signatures. Substantiation status is not explicitly stated.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure the fall risk rating was reviewed and updated after a fall for resident #1. |
| The facility did not ensure that the Medication Administration Record included signatures for administered medications for residents #1 and #2 on 11/21/24. |
Report Facts
Medication administration signature audit duration: 4
Fall risk rating audit percentage: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as the current inspector conducting the inspection. |
Inspection Report
Monitoring
Census: 32
Deficiencies: 0
Nov 6, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the area of Personnel.
Findings
The inspection found no violations with applicable standards or laws. No deficiencies were identified during the inspection.
Report Facts
Number of residents present: 32
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 33
Deficiencies: 10
Oct 8, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for continued licensure of the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including missing cognitive impairment assessments, incomplete documentation for special care unit placement, lack of disclosure statements, missing annual tuberculosis risk assessments, failure to update fall risk ratings after falls, incomplete resident orientation documentation, missing Uniform Assessment Instruments prior to admission, incomplete individualized service plans, and failure to provide or document medical procedures and treatments as ordered by physicians.
Deficiencies (10)
| Description |
|---|
| Facility did not ensure prior to admission a resident was assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility did not ensure determination and justification for placement in special care unit was documented and signed. |
| Facility did not provide a disclosure statement to prospective resident or legal representative. |
| Facility did not ensure annual tuberculosis risk assessment was completed for each resident. |
| Facility did not ensure fall risk rating was reviewed and updated after a fall. |
| Facility did not ensure orientation was provided and documented for new residents and their legal guardians. |
| Facility did not ensure Uniform Assessment Instrument was completed prior to admission and signed by authorized personnel. |
| Facility did not ensure preliminary plan of care or individualized service plan was developed on or within 7 days prior to admission. |
| Facility did not ensure individualized service plans were signed and dated by licensee, administrator, or designee and resident or legal guardian. |
| Facility did not ensure medical procedures or treatments ordered by a physician were provided and documented in the resident's record. |
Report Facts
Number of residents present: 33
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of interviews conducted with staff: 3
Number of interviews conducted with residents: 0
Number of observations by licensing inspector: 3
Audit percentage: 5
Timeframe for compliance: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff #1 | Staff member who confirmed missing documentation in resident records | |
| Executive Director | Named in multiple plans of correction related to retraining and audits | |
| Sales Manager | Named in plans of correction for retraining regarding admission documentation | |
| Health and Wellness Director | Named in plans of correction for retraining and audits related to health assessments and documentation | |
| Resident Care Coordinator | Named in plans of correction for retraining and audits | |
| Business Office Manager | Named in plans of correction for auditing orientation documentation |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Oct 8, 2024
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 2024-09-06 and 2024-09-09 regarding allegations in the areas of Personnel, Staffing and Supervision, Resident Care and Related Services, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of Resident Care and Related Services, resulting in a violation notice being issued. The licensee was given the opportunity to submit a plan of correction to address the cited violations.
Complaint Details
The complaint investigation was substantiated in part, with evidence supporting non-compliance in Resident Care and Related Services. Some allegations were not supported.
Deficiencies (3)
| Description |
|---|
| The facility did not ensure the fall risk rating was reviewed and updated after a fall. |
| The facility did not ensure upon admission that an orientation was provided to new residents and their legal guardians, including emergency response procedures, mealtimes, and use of the call system, with signed acknowledgment. |
| The facility did not ensure the Uniform Assessment Instrument (UAI) was completed prior to admission. |
Report Facts
Number of residents present: 33
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of interviews conducted with staff: 3
Number of interviews conducted with residents: 0
Number of observations by licensing inspector: 3
Number of falls documented for resident #1: 5
Audit percentage: 5
Timeframe for reviews: 2
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Jun 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-06-10 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified regarding improper documentation of Do Not Resuscitate (DNR) orders in the Individualized Service Plan (ISP).
Complaint Details
Complaint was received on 2024-06-10 regarding Resident Care and Related Services. The evidence gathered did not support the allegation(s) of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that Do Not Resuscitate (DNR) orders were properly documented in the Individualized Service Plan (ISP) as required. |
Report Facts
Number of residents present: 33
Number of resident records reviewed: 4
Number of staff records reviewed: 1
Number of resident interviews conducted: 3
Number of staff interviews conducted: 1
Number of observations by licensing inspector: 3
Plan of correction completion date: Oct 2, 2024
Date complaint received: Jun 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff #1 | Confirmed that the DNR order was not properly documented on the Individualized Service Plan |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Jan 22, 2024
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2024-01-02 regarding allegations in Resident Care and Related Services and Staffing and Supervision.
Findings
The investigation supported some, but not all, allegations. Deficiencies were found in Resident Care and Related Services, including failure to implement a written medication management plan and failure to ensure PRN medications were available, properly labeled, and stored.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services. The complaint was received by VDSS Division of Licensing on 2024-01-02 and related to Resident Care and Staffing and Supervision.
Deficiencies (2)
| Description |
|---|
| Failed to implement a written plan for medication management to ensure accurate counts of all controlled substances during staff shift changes. |
| Failed to ensure medications ordered for PRN administration were available, properly labeled for the specific resident, and properly stored at the facility. |
Report Facts
Number of residents present: 32
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the complaint investigation |
| Donesia Peoples | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
| Health & Wellness Director | Provided re-in-service to nursing staff and ordered medications as part of plan of correction | |
| Executive Director | Responsible for auditing controlled substance book and medication cart as part of plan of correction |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 3
Nov 28, 2023
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2023-11-09 regarding allegations in Resident Care and Related Services and Personnel.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations included failure to ensure individualized service plans were signed, inadequate personal assistance with bathing, and failure to document required resident rounds every two hours.
Complaint Details
Complaint was substantiated in part; violations related to Resident Care and Related Services were found. The complaint was received on 2023-11-09 and involved allegations in Resident Care and Personnel.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or designee, and by the resident or legal guardian. |
| Facility failed to ensure personal assistance and care, including bathing twice a week or more if needed, was provided as required. |
| Facility failed to ensure documentation of resident rounds every two hours for residents unable to use signaling devices. |
Report Facts
Residents present: 36
Resident records reviewed: 4
Staff records reviewed: 0
Staff interviews conducted: 2
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 36
Deficiencies: 1
Nov 28, 2023
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegation of non-compliance with standards or law; however, violations unrelated to the allegation were identified. Specifically, the facility failed to ensure the individualized service plan (ISP) included all required documentation of identified resident needs.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) included a description of identified needs based on the admission physical examination and other sources for resident #1. |
Report Facts
Number of residents present: 36
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding the inspection |
| Lanesha Allen | Licensing Inspector | Inspector on-site during the inspection |
| Health & Wellness Director | Health & Wellness Director | In-serviced staff and updated resident's ISP as part of plan of correction |
| Health & Wellness Coordinator | Health & Wellness Coordinator | In-serviced staff as part of plan of correction |
Inspection Report
Renewal
Census: 38
Deficiencies: 6
Oct 26, 2023
Visit Reason
An unannounced renewal inspection was conducted to evaluate compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found multiple violations including failure to report suspected abuse timely, lack of appropriate psychotropic medication treatment plans, delayed tuberculosis risk assessments, incomplete individualized service plans, failure to review resident rights annually on time, and medication management deficiencies including expired medications and improper documentation.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure all mandated reporters reported suspected abuse, neglect, or exploitation of residents in accordance with the Code of Virginia. |
| Facility failed to ensure assisted living facilities do not admit or retain individuals on psychotropic medications without appropriate diagnosis and treatment plans. |
| Facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident. |
| Facility failed to ensure the comprehensive individualized service plan (ISP) included descriptions of identified needs based on assessments and physical exams. |
| Facility failed to ensure residents' rights and responsibilities were reviewed annually with each resident or legal guardian on time. |
| Facility failed to implement a written plan for medication management to prevent use of outdated medications and ensure accurate transcription of medication orders within 24 hours. |
Report Facts
Number of residents present: 38
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 5
Expired medication packs: 3
Inspection Report
Monitoring
Census: 34
Deficiencies: 1
Aug 22, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in Personnel and Resident Care and Related Services.
Findings
The investigation did not support the allegations of non-compliance, but violations unrelated to the allegations were identified, including failure to maintain current first aid certification for a direct care staff member.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure direct care staff member maintained current certification in first aid. |
Report Facts
Number of residents present: 34
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 7
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Aug 22, 2023
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2023-08-17 regarding allegations in the areas of Building and Grounds and 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 by VDSS Division of Licensing on 2023-08-17 regarding allegations in Building and Grounds and Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 2
Resident interviews conducted: 1
Staff interviews conducted: 7
Inspection Report
Monitoring
Census: 36
Deficiencies: 2
Aug 8, 2023
Visit Reason
An unannounced complaint inspection was conducted on August 8, 2023, following a self-report received on July 27, 2023, regarding allegations in Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified, including failure to report major incidents within 24 hours and failure to ensure individualized service plans were signed by residents or their legal guardians.
Complaint Details
The complaint was not substantiated based on the evidence gathered during the investigation.
Deficiencies (2)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| Facility failed to ensure the individualized service plan (ISP) was signed by the resident or legal guardian. |
Report Facts
Residents present: 36
Resident records reviewed: 1
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Jan 18, 2023
Visit Reason
An unannounced complaint inspection was conducted on January 18, 2023, following a complaint received on January 6, 2023, regarding allegations in the areas of Staffing and Supervision and Building and Grounds.
Findings
The investigation did not support the allegation of non-compliance with standards or law. However, a violation unrelated to the complaint was identified regarding the failure to ensure resident bedrooms contained required furniture items such as a table, sturdy chair, and drawer space.
Complaint Details
Complaint was received by VDSS Division of Licensing on 01/06/2023 regarding allegations in the areas of Staffing and Supervision and Building and Grounds. The evidence gathered did not support the allegation of non-compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure bedrooms contained a table or its equivalent accessible to each bed, a sturdy chair for each resident, and drawer space for clothing and personal items. |
Report Facts
Residents present: 27
Resident records reviewed: 2
Staff records reviewed: 2
Resident interviews conducted: 2
Staff interviews conducted: 3
Inspection Report
Renewal
Census: 29
Deficiencies: 5
Oct 31, 2022
Visit Reason
An unannounced renewal inspection was conducted on-site to assess compliance with applicable standards and laws for facility licensing renewal.
Findings
The inspection found multiple violations including failure to ensure residents with prohibitive conditions were properly admitted or retained, incomplete individualized service plans, medication management deficiencies, and lack of proper documentation such as psychotropic treatment plans and sex offender registry checks.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure admit or retain individuals with any prohibitive conditions or care needs, including missing psychotropic treatment plan for resident #2. |
| Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender for residents with length of stay greater than three days. |
| Facility failed to ensure individualized service plans included all assessed needs for two of five records reviewed. |
| Facility failed to ensure its medication management plan was implemented, including missing medications and discontinued medications present on medication carts. |
| Facility failed to ensure medications ordered for PRN administration were available, properly labeled, and properly stored. |
Report Facts
Inspection dates: 4
Facility census: 29
Resident records reviewed: 5
Resident records audited monthly: 10
Inspection Report
Monitoring
Census: 28
Deficiencies: 6
Aug 23, 2022
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with personnel, admission, retention, discharge of residents, and resident care and related services regulations.
Findings
The inspection found multiple violations including failure to keep first aid/CPR certification listings up to date, failure to update fall risk ratings after resident falls, incomplete resident personal and social data forms, individualized service plans not reflecting all assessed needs or lacking required signatures, and incomplete medication administration records.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure the first aid/CPR listing posted was kept up to date. |
| Facility failed to ensure the fall risk rating was reviewed and updated after a fall. |
| Facility failed to ensure the resident's personal and social data information was kept current for four of six residents' records. |
| Facility failed to ensure the individualized service plan included all assessed needs for six of six records reviewed. |
| Facility failed to ensure the individualized service plan was signed and dated by the resident or legal representative. |
| Facility failed to ensure the medication administration record included all required information. |
Report Facts
Inspection dates: 3
Staff census: 28
Plan of correction due date: Oct 12, 2022
Residents with personal/social data issues: 4
Residents with ISP deficiencies: 6
Inspection Report
Renewal
Census: 31
Deficiencies: 10
May 31, 2022
Visit Reason
A two-day on-site unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including unsafe environmental conditions on the secure unit, incomplete resident physical examinations, missing or outdated resident personal and social data, incomplete individualized service plans, failure to coordinate hospice care plans, medication administration errors, and improper medication storage and handling.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure harmful materials were inaccessible to residents on the safe, secure unit. |
| Resident's admitting physical examination was not completed within 30 days preceding admission and lacked required information. |
| Resident personal and social data forms were incomplete or not kept current. |
| Individualized service plans did not include all assessed needs for residents. |
| Hospice care services were not properly communicated or included in individualized service plans. |
| Individualized service plans were not updated to reflect significant changes in residents' conditions. |
| Menus for meals and snacks were not dated and posted conspicuously for residents. |
| Medications were not administered according to prescriber's instructions, including a medication error with an antibiotic. |
| Medications ordered for PRN administration were not available or properly stored. |
| Stat-drug medications were administered by unlicensed staff contrary to regulations. |
Report Facts
Inspection days: 2
Residents reviewed: 6
Residents with incomplete personal/social data: 4
Residents with incomplete ISP: 6
Residents with hospice care issues: 2
Residents with ISP not updated for significant change: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current inspector conducting the inspection. |
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Feb 14, 2022
Visit Reason
An unannounced complaint inspection was conducted on 2022-02-14 regarding allegations that resident care and medications were not properly managed, and residents had wounds on the sacral area.
Findings
The inspection found multiple deficiencies including failure to report major incidents within 24 hours, incomplete and unsigned Uniform Assessment Instruments, individualized service plans that did not include all assessed needs or hospice services, lack of timely updates to service plans, and failure to document medical treatments as ordered by physicians.
Complaint Details
The complaint was substantiated based on interviews and record reviews indicating inadequate resident care and medication management, including wounds on residents.
Deficiencies (7)
| Description |
|---|
| Failure to report to the regional licensing office within 24 hours any major incident negatively affecting residents. |
| Uniformed assessment instrument (UAI) not signed by administrator or designee. |
| Individualized service plan (ISP) did not include all assessed needs for residents. |
| Failure to ensure hospice services were included in the individualized service plan. |
| Individualized service plan (ISP) was not signed and dated by the license, administrator, or designee and resident or legal representative. |
| Individualized service plan (ISP) was not reviewed and updated at least once every 12 months or as needed. |
| Failure to ensure medical procedures or treatments ordered by a physician were provided according to instructions and documented. |
Report Facts
Inspection dates: 4
Plan of correction due date: 10
Inspection Report
Complaint Investigation
Deficiencies: 11
Aug 12, 2021
Visit Reason
A non-mandated complaint inspection was initiated on 2021-08-12 and concluded on 2021-11-19 following a complaint regarding resident care, staff training and knowledge, oxygen care and training, and staff attitude.
Findings
The investigation found multiple violations including insufficient cognitive impairment training for staff, failure to implement infection control protocols, lack of psychotropic medication treatment plans, incomplete individualized service plans (ISP), medication management deficiencies, and inadequate staff training on oxygen equipment use. Several residents' care needs and medication orders were not properly documented or followed.
Complaint Details
The complaint investigation was initiated due to allegations concerning resident care, staff training and knowledge, oxygen care and training, and staff attitude. The evidence gathered supported the allegations of non-compliance with standards or law, resulting in violations issued.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure direct care staff attended at least 10 hours of cognitive impairment training within four months of employment. |
| Facility failed to implement infection control protocol during blood glucose observation. |
| Facility failed to admit or retain individuals with psychotropic medication without a treatment plan for three of four records. |
| Individualized service plans (ISP) did not include all assessed needs for residents. |
| Resident individualized service plans (ISP) were not reviewed and updated as the resident's condition changed. |
| Facility failed to ensure resident's prescription medications and supplements were filled and refilled timely to avoid missed dosages. |
| Facility failed to ensure medications were started, changed, or discontinued only with valid physician or prescriber orders. |
| Physician or prescriber orders did not identify diagnosis, condition, or specific indications for administering each drug. |
| Resident medication was not administered in accordance with physician's or prescriber's instructions and standards of practice. |
| Direct care staff responsible for assisting residents with oxygen supplies lacked documentation of training. |
| Facility failed to keep furnishings, fixtures, and equipment clean and in good repair, including bathroom vent and commode in room #15. |
Report Facts
Inspection dates: 5
Cognitive impairment training hours: 9.25
Cognitive impairment training hours: 6.7
Plan of correction deadlines: 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the investigation. |
| Clare Bridge | Program Coordinator | Responsible for providing training or retraining on cognitive impairment for staff. |
| Staff #1 | Acknowledged multiple deficiencies including lack of training, incomplete ISPs, and medication order issues during exit interviews. | |
| Staff #3 | Mentioned in relation to cognitive impairment training hours. | |
| Staff #4 | Mentioned in relation to cognitive impairment training hours and oxygen training. | |
| Staff #5 | Mentioned in relation to cognitive impairment training hours and oxygen training. | |
| Staff #9 | Observed during medication and blood glucose observation with infection control deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 1, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care and related services at Brookdale Virginia Beach. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation found non-compliance with standards, including failure to update Individualized Service Plans (ISP) for significant changes in resident conditions and failure to make and document rounds every two hours for residents unable to use signaling devices. Violations were issued based on these findings.
Complaint Details
The complaint investigation was initiated on 2021-06-01 and concluded on 2021-06-08. The complaint was related to resident care and related services. The evidence supported the allegation of non-compliance with standards or law, resulting in violations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) was updated as needed for a significant change in a resident's condition. |
| Facility failed to make and document rounds no less than every two hours for each resident with an inability to use the signaling device. |
Report Facts
Inspection dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 26
Deficiencies: 2
May 4, 2021
Visit Reason
A renewal inspection was initiated on May 4, 2021 and concluded on May 7, 2021 to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified non-compliances including failure to ensure a resident had a physical examination within 30 days preceding admission and failure to ensure timely refill of prescription medications to avoid missed dosages.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a person had a physical examination within 30 days preceding admission. |
| Facility failed to ensure methods that each resident's prescription medications are refilled in a timely manner to avoid missed dosages. |
Report Facts
Missed medication dosages: 19
Census: 26
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 11, 2021
Visit Reason
A complaint inspection was initiated on March 5, 2021, regarding allegations in the areas of medication administration and resident care at Brookdale Virginia Beach.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued related to failure to review Individualized Service Plans as resident conditions changed and failure to administer medications according to prescriber's instructions.
Complaint Details
The complaint was substantiated. It involved allegations of medication administration errors and inadequate resident care, specifically related to Resident #1's combative behaviors and medication transcription errors.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure Individualized Service Plans (ISPs) were reviewed as needed as the condition of the resident changed. |
| Facility failed to ensure medications were administered in accordance with the prescriber's instructions, including a transcription error resulting in incorrect medication administration for 13 days. |
Report Facts
Inspection dates: 4
Incidents of combative behavior: 13
Days medication administered incorrectly: 13
Months for ongoing compliance audits: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current inspector conducting the complaint investigation |
| Health & Wellness Director or Designee | Responsible for collaborating with medical providers, reassessing ISPs, conducting audits, and providing staff education | |
| Regional Dementia Care Specialist | Involved in providing education to staff regarding behavioral approaches | |
| Executive Director | Contacted by telephone for investigation and involved in staff education | |
| Staff #1 and Staff #2 | Confirmed deficiencies related to ISP and medication administration during interviews |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 3
Nov 20, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding incident reports, individualized service plans, signaling and call systems, personal care services, staffing and supervision, food service and nutrition, and maintenance of buildings and grounds.
Findings
The investigation supported allegations of non-compliance with standards or law, resulting in violations related to staffing ratios, incomplete work schedules, and medication administration errors.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, confirming violations in staffing, scheduling, and medication administration.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure adequate awake direct care staff on duty in special care units according to resident census. |
| Written work schedules did not include names, job classifications, or indicate staff in charge, substitutions, or changes. |
| Medications were not administered in accordance with physician's instructions, resulting in a medication error for Resident #5. |
Report Facts
Inspection dates: 5
Residents present: 25
Medication doses administered: 2
Report
File
Inspection_28884_ID_36812.pdf
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