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Spring Arbor of Williamsburg
935 Capitol Landing Road
Williamsburg, VA 23185
(757) 565-3583

Current Inspector: Kimberly Rodriguez (757) 586-4004

Inspection Date: March 13, 2018 and March 14, 2018

Complaint Related: No

Areas Reviewed:
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
32.1 Report by person other than physician
63.2 Protection of adults and reporting.
22VAC40-90 Background Checks for Assisted Living Facilities
22VAC40-90 The Sworn Statement or Affirmation
22VAC40-90 The Criminal History Record Report

Comments:
An unannounced renewal inspection was conducted on 3-13-18 and 3-14-18. The census on 3-13-18 was 74. A medication pass observation was conducted, breakfast meal was observed and lunch preparation observed, activity was observed, interviews were conducted, staff and resident records reviewed. The administrator was present both days. An exit interview was conducted with the administrator and resident care coordinator on both days and the acknowledgement document was signed by the administrator on both days. Comment: The facility's resident's service plan was discussed with staff and the administrator, the facility signaling device was discussed on both days with the administrator and care coordinator. The call bell was pulled on both days following resident interviews and staff did not have the walkie talkie to know hear the call. The new regulation requirement for new admission was discussed, various areas of the standard were reviewed during the inspection. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days from today. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. Plan of correction is due with 10 days.(4-9-18).

Violations:
Standard #: 22VAC40-73-70-A
Description: Based on record reviewed, document reviewed and staff interviewed, the provider failed to report to the regional licensing office within 24 hours an incident that has negatively affected a resident. Evidence: 1. During a review of the sampled resident's record with staff B2 it was revealed that resident #7's record indicated the resident was admitted to the facility with a stage 2, admitting documents, December 2017. Resident was also diagnosed with a stage 2 to the sacral by the nurse from the agency providing wound care services. The documentation by the home health agency, dated 1-3-18 indicated stage 2 to sacral. 2. A discussion was held with staff B2 regarding reporting stage 2 to the department.

Plan of Correction: It is Spring Arbor of Williamsburg's to comply with all state regulations regarding the facility reporting to the regional licensing office by the next working day any major incident that has negatively affected the life, health, safety or welfare of any resident. The Resident Care Director and all Med Tech's/LPN's have been In-Serviced on the reporting protocols. The Resident Care Director and/or designee will verbally report, within 24 hours and in writing, within 7 days, any major incident that negatively affects the life, health, safety or welfare of any resident to the regional licensing office and monitor weekly for on-going compliance.

Standard #: 22VAC40-73-260-A
Description: Based on record reviewed, document reviewed and staff interviewed, the provider failed to ensure direct care staff had required first aid certification from an approved provider. Evidence: 1. During a review of the staff records with staff #1, it was revealed that staff #NH-1's first aid card was not from an approved source. Staff's date of hire was documented as 12-27-17. 2. A copy of the card was request and received. A discussion was held with staff #1 regarding the approved certification sources for first aid.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding First Aid training from the Department of Social Services approved provider list. The Business Office Manager will ensure all employees receive lst Aide /CPR training within 60 days of hire from an approved provider. All employee files were reviewed and are fully compliant with state regulations regarding First Aide/CPR training.

Standard #: 22VAC40-73-310-H
Description: Based on record reviewed and staff interviewed, the provider failed to ensure it did not retain and/or admit residents with any the prohibitive conditions without required documents for three of ten residents. Evidence: 1. During a review of the sampled resident's records with staff B2, it was revealed that the following records did not contain documentation of a treatment plan for psychotropic medication. 2. Resident #3's record indicated resident prescribed klonopin. A document requesting treatment plan information and dated 12-9-16 by facility staff was faxed to the resident's physician. However, there was no date of the physician's response. 3. Resident #4's record indicated resident prescribed zoloft. A document requesting treatment plan information and dated 4-27-17 and 4-28-17 by facility staff was faxed to the resident's physician. However, there was no documentation of the physician's response. 4. Resident #5's record indicated resident prescribed celexa and zyprexa. A document requesting treatment plan information for zyprexa and dated 2-27-18 and 3-2-18 by facility staff was faxed to the resident's physician. Also reviewed was a faxed document requesting treatment plan information for celexa and dated 3-2-18 and 3-8-18 by the facility staff. However, there was no documentation of the physician's response. 5. A discussion was held with staff B2 regarding resident's with psychotropic medication and the treatment plan requirement.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding Psychotropic medications. The Resident Care Director or designee, receiving the psychotropic order will review for accuracy and ensure that the treatment plan is in place. If it is not, the Resident Care Director or designee will immediately contact the physician to obtain the appropriate treatment plans. The Resident Care Director or designee will provider on-going compliance of this policy by conducting daily reviews of new orders.

Standard #: 22VAC40-73-450-C
Description: Based on record reviewed, document reviewed and staff interviewed, the provider failed to ensure the comprehensive individualized service plan (ISP) included all identified needs as identified upon the uniformed assessment instrument (UAI), physical examination or other sources. Evidence: 1. A review of the sampled resident's record with staff B2, it was revealed that the following resident's ISP did not include all documented assessed needs. 2. Allergy information was not identified on the ISP for the following residents: (a) resident #1's physical examination dated 9-27-16 indicated allergy to statin, codeine and exelon, however, information not on ISP dated 9-28-17; (b) resident #2's physical examination dated 2-27-17 indicated allergy to sulfa, however, information not on ISP dated 4-23-17; (c) resident #3's physical examination dated 3-31-16 indicated allergy to sulfa, however, information not on ISP dated 9-18-17; (d) resident #7's physical examination dated 12-1-17 indicated allergy to cipro and codeine, however, information not on ISP dated 1-14-18; (e) resident #8's March 2017's medication administration record (mar) noted several allergy- zetia, vicodin, lipitor, zocor, crestor, statins an phenergan.and (f) resident #9's March 2017 mar noted allergy to losartan and iodine dye; however, the information not on ISP dated 10-1-17. 3. Dietary information not correctly documented on the ISP for the following residents: (a) resident #4's physician's order dated 1-18-18 indicated no added salt(nas), however the ISP dated 12-23-17 indicated a regular diet and (b) resident #6's physician's order dated 2-19-18 indicated nas (mechanical soft) diet, however, the ISP dated 1-17-18 indicated a regular diet. 4. Resident #9's record included physician's order, dated 1-16-18, to self-administer over the counter (otc) aleve & aleve pm, however, information not included on ISP dated 4-23-17. 5. A discussion was held with staff B2 regarding ISP requirement for all needs identified for a resident and ISP information, including therapy and other not needs not on the uniformed assessment instrument (uai).

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding Individualized Service Plans (ISP) reflecting a resident's needs as assessed and supporting the principals of individuality, personal dignity, and freedom of choice in a home like environment. The Resident Care Director, Cottage Care Coordinator, and Executive Director will review all Individualized Service Plans (ISP) to reflect any changes. This review will include observations and recommendations from other health care service providers as appropriate, allergy information, diet orders and self-administer orders. The Resident Care Director and/or Cottage Care Coordinator will review all Individualized Service Plans (ISP) with the resident and/or personal representative when changes are made in care.

Standard #: 22VAC40-73-450-E
Description: Based on record reviewed, document reviewed and staff interviewed, the provider failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative for two of ten resident. Evidence: 1. During a review of the sampled resident's record with staff B2, it was revealed that resident #5 was admitted to the facility on 2-26-18. A review of the 72-hour ISP and the comprehensive ISP did not include the signature of the resident or resident's representative's signature on either document. 2. A review of resident #9's ISP revealed hospice services was started on 1-17-18, the information is noted on the resident's ISP dated 10-1-17. However, the updated ISP was not signed by the resident or legal representative. 2. A discussion was held with staff #B2 regarding the ISP requirements for resident's admitted following the new regulation's effective date of February 1, 2018 and reviews required to be signed also by the resident and/or legal representative.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding obtaining the signature and date from the resident and/or his legal representative. The Resident Care Director and/or cottage Care Coordinator will review and obtain signatures of all Individualized Services Plans (ISP) with the resident and /or his/her legal representative. all Individualized Services Plans were reviewed and are fully compliant with signatures of the resident and his or her legal representative.

Standard #: 22VAC40-73-450-F
Description: Based on record reviewed, document reviewed and staff interviewed, the provider failed to ensure the individualized service plan (ISP) was reviewed and updated as needed as the condition of the resident change for four of ten resident. Evidence: 1. During a review of the sampled resident's record with staff B2 it was revealed that resident #3's ISP was not updated to reflect therapy services being provided by home health agency. A review of a physician's order for physical therapy evaluation and treat was dated 9-7-17. Further review of therapy documentation indicated initial service visit was dated 8-21-17. The staff was not sure when services began. Another notation by the service provider indicated a recertification date 11-21-17 and services discontinued on 12-14-17. This information was not documented on the resident's ISP dated 9-18-17. 2. Resident #6's record noted a home-health agency providing physical therapy services. A documentation in the record on 11-15-17 indicated resident's physical therapy. Another documentation indicated recertification of services on 2-11-18. This information was not documented on the resident's ISP dated 1-17-18. 3. Resident #8's record note a home-health agency providing skilled nursing services. The record indicated skilled nursing documentation on 7-29-17 and skilled nursing services discontinued date noted on 9-21-17. The record also indicated occupational therapy services 8-1-17 and services discontinued on 8-28-17. The record also indicated resident began physical therapy services 11-17-17. However, the ISP dated 4-23-17 did not document services received by resident. 4. Resident #9's record indicated physical and occupational therapy services were continued as of 12-12-17. However, the ISP dated 10-1-17 did not reflect the continued services. 5. A discussion was held with staff B2 regarding home-health services received by the resident, whether in-house or an outside agency, the information should be on the resident's ISP when service is received, recertified and discontinued information should be documented on the ISP.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding Individualized Service Plans (ISP). The Resident Care Director and/or Cottage Care coordinator will provide on-going compliance of this policy by reviewing and updating the resident's Individualized Service Plan (ISP) at the completion of services or when goals are met, changed, and /or discontinued.

Standard #: 22VAC40-73-580-C
Description: Based on observation and staff interviewed, the provider failed to ensure personnel was available to help any resident who may need assistance when eating in the dining room. Evidence: 1. During an observation of the breakfast meal, on 3-13-18 at 8:05 am, there were nine residents in the dining room consuming their meals. However, there was no staff available in the dining room. 2. Staff S-1 came to the area where the inspector was standing. The inspector inquired of staff where the dining room staff was and that the inspector was standing in the area for about five minutes and did not observe a staff present. 3. A staff did enter the dining room from the kitchen area but did not remain in the dining room but returned to the kitchen. The dietary staff was in and out of the area, but a staff did not remain in the area during the meal. The inspector discussed what was observed with staff D4 and B2.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding having personnel available to help any resident who requires assistance in the dining room or when eating. The Food service Director will ensure that at least one server is stationed in the dining room at all times when residents are seated in dining room.

Standard #: 22VAC40-73-610-D
Description: Based on record reviewed, observation, document reviewed and staff interviewed, the provider failed to ensure when a diet is prescribed for a resident by his physician or other prescriber, it was prepared and served according to the physician's or other other prescriber's orders for two of ten residents. Evidence: 1. During a review of the breakfast and lunch meal it was observed that the food preparation being prepared by the kitchen staff, cooks were prepared the same for residents. Those who were assessed as no added salt, no added sugar, low fat, low cholesterol were all served from the same food container. 2. A review of the sampled resident's record with staff B2 revealed resident #1's physician's order dated 1-14-18 indicated low cholesterol/ low fat diet. 3. A review of resident #9"s record revealed that resident's diet was low fat/low salt. 4. The inspector was in the kitchen during the lunch meal preparation and did not observe a different preparation for the lunch meal for residents with low-fat/low cholesterol or low salt diet. 5. The inspector discussed with staff D4 what was observed during preparation. There was no difference in the preparation of the meal served. Those with regular, low fat, low cholesterol dietary requirements were all served from the same food preparation/container.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding providing low fat/low cholesterol diets. The Director of Quality and Education reviewed menu plans specific to this diet. Food Service Director reviewed diets and educated dietary staff. the Food Service Director or designee will ensure low fat, low cholesterol meals are prepared and kept separately for residents with this prescribed diet order.

Standard #: 22VAC40-73-650-B
Description: Based on document reviewed and staff interviewed, the provider failed to ensure the physician or other prescriber's orders for administration of a prescription included the diagnosis, condition, or specific indications for administering a drug for one of ten resident. Evidence: 1. During a review of the sampled resident's record with staff B2, it was revealed that resident #7 was prescriber keflex. A review of the physician's order, 3-1-18 did not include a diagnosis. A document requesting information by facility staff was faxed to the physician. However, there was no response as of the day of the inspection. 2. A discussion was held with staff B2 regarding the missing information.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding Physician's or other prescriber's orders. The individual reviewing the order will ensure each order includes the name of the resident, the date of the order, the name of the drug, route, dosage, an strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. The Resident Care Director or designee will provider on-going compliance of this policy by conducting daily reviews of new orders.

Standard #: 22VAC40-73-680-I
Description: Based on document reviewed and staff interviewed, the provider failed to ensure the resident medication administration record (mar) included all required information for one of ten residents. Evidence: 1. During a review of the sampled resident's record with staff B2, it was revealed that the following resident's Mar did not indicate the diagnosis, condition, or specific indications for administering the drug prescribed. 2. Resident #5's February 2018's mar did not indicate a diagnosis for furosemide. 3. A discussion was held with staff B2 regarding the missing information on the mar.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding Physician's or other prescriber's orders. The individual reviewing the order will ensure each order includes the name of the resident, the date of the order, the name of the drug, route, dosage, and strength, how often the medications is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. The Resident Care Director or designee has reviewed every prescriber's order to ensure compliance with state regulations regarding Physician's or other prescriber's orders. The Resident Care Director or designee will provide on-going compliance of this policy by conducting daily reviews of new orders.

Standard #: 22VAC40-73-720-A
Description: Based on record reviewed, document reviewed and staff interviewed, the provider failed to ensure the do not resuscitate (dnr) was included in one of ten resident's individualized service plan (ISP). Evidence: 1. During a review of the sampled resident's record with staff B2, it was revealed that resident #6's record included a dnr document dated 11-14-16. A review of the resident's ISP dated 1-7-18 indicated the resident was a full-code. A review of the resident's signed physician's order dated 2-19-18 also indicated resident as a dnr. 2. The information reviewed was discussed with staff #B2.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulations regarding Individualized Service Plan (SP) reflecting a resident's needs as assessed and supporting the principals of individuality, personal dignity, and freedom of choice in a home like environment. The Resident Care Director and/or Cottage Care Coordinator have reviewed all Physician's Orders related to resident code status. All Individualized Service Plans reflect each residents correct code status. The Resident's Care Director and/or Cottage Care Coordinator will provide on-going compliance of this policy by reviewing all resident's code status and Physician's Orders monthly.

Standard #: 22VAC40-73-980-C
Description: Based on observation and staff interviewed, the provider failed to ensure the first aid kit was checked at least monthly. Evidence: 1. During a check of the first aid kit on the safe, secure unit with staff C3, it was revealed that the first aid check list was not completed for the month of February 2018. 2. Staff stated it should be checked and the checklist completed every month.

Plan of Correction: It is Spring Arbor of Williamsburg's policy to comply with all state regulation ensuring that the first aid kits are checked monthly. The Resident Care Director and Cottage Care Coordinator will ensure that each first aid kit checklist is completed monthly.

Disclaimer:
A compliance history is in no way a rating for a facility++.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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