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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: Aug. 23, 2018

Complaint Related: No

Areas Reviewed:
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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Article 1
Subjectivity

Comments:
An unannounced monitoring inspection was conducted on 8-23-18 (arrival departure) regarding a notification to the department of a resident who "eloped from the facility". The resident's record, facility documents and interviews with staff and collateral interviews were conducted during the inspection. An exit interview was conducted with the administrator and the acknowledgement form was signed by the administrator. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. 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. POC due 9-28-18.

Violations:
Standard #: 22VAC40-73-1090-A
Description: Based on record review and staff interview, the facility failed to ensure prior to admission to the safe, secure environment, the resident was assessed by an independent clinical psychologist licensed to practice in the Commonwealth or an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. On 7-26-18 during the inspector?s interview with staff #4, following notification to the inspector on 7-25-18 of resident #?1 ?elopement from the facility on 7-25-18? it was revealed that the resident was placed on the special care unit upon return to the facility. According to staff #4,? the resident was taken to special care unit and had lunch?. 2. On 8-23-18 during a review of resident #1's record with staff #1 and #2, the inspector observed the documented ?Assessment of Serious Cognitive Impairment? form noted assessment of the resident's cognitive status and assessment for placement on the safe, secure unit (scu) was signed and dated by the physician on 7-30-18. 3. During further interview with staff #1 and #2, on 8-23-18, staff acknowledged the resident was relocated to the scu on 7-25-18. Both staff indicated being informed that ?the resident could be place on the safe, secure unit for an emergency and for safety reasons?. 4. Staff #1 and #2 confirmed resident was placed on scu on 7-25-18, prior to the physician?s assessment dated 7-30-18.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding the assessment of the resident prior to admission to a safe, secure unit. Before any resident is admitted into the safe, secure unit an assessment by an independent clinical psychologist licensed to practice in the Commonwealth or an independent physician will be performed. This requirement was reviewed with the Resident Care Director and the Cottage Care Coordinator by the Regional Nurse on 09/27/2018. Spring Arbor received the signed Assessment of Serious Cognitive Impairment document from resident?s Physician on 07/30/2018. The Executive Director and/or designee will review each admission to ensure the appropriate documentation is in place before admitting a resident to the special care unit. Compliance Date: 07/30/2018

Standard #: 22VAC40-73-450-F
Description: Based on record review and staff interview, the facility failed to ensure a resident?s individualized service plan (ISP) was updated as the condition of the resident changes. Evidence: 1. During a review of resident #1?s record on 8-23-18 with staff #2, regarding resident #1's being absent from the facility without any staff's knowledge, the resident?s ISP did not include documentation of the resident?s recent need for placement on the safe, secure unit (scu). The ISP in the record on the day of the inspector?s review of resident #1?s record was dated 3-20-18. The inspector?s interview with staff #1 and #2 revealed resident #1 was placed on the scu on 7-25-15. 2. During a review of resident #1?s record on 8-23-18 with staff #2, the most current ISP dated 3-20-18 was not updated to include documentation of the resident?s need for placement on the scu.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding Individualized service plans. All Individualized service plans (ISP?s) will be updated at least every 12 months and as needed as the condition of the resident changes. This standard was reviewed with the Resident Care Director and the Cottage Care Coordinator by the Regional Nurse on 09/27/2018. The Cottage Care Coordinator updated the residents ?ISP? on 08/27/2018. The Resident Care Director and/or designee will complete monthly ?ISP? audits to confirm any new conditions are addressed and to assure compliance. Compliance Date: 08/27/2018

Standard #: 22VAC40-73-460-D
Description: Based on record review and staff interview, the facility failed to ensure it provided supervision of a resident's schedule, including attention to wandering from the premises. Evidence: 1. During the inspector?s interview with staff # 3 regarding a report to the licensing office regarding resident #1?s absence from the facility without staff?s knowledge, staff #3 stated, "resident #1 was not her usual self and was very confused. Resident #1 was outside the facility on the side walk. Resident #1 stated going home and not coming back in the building?. Staff #3 stated encouraging the resident #1 back inside the facility and had the resident to sit on the bench in the lobby, unsupervised, to wait for resident #1?s family member?. 2. The inspector?s review of resident #1?s record and a document entitled ?Resident Notes? dated 7-25-18 at 9:10 am confirmed staff #3?s description of what occurred on the morning when resident #1 left the facility. 3. Further review of the document entitled ?Resident Notes? in resident #1?s record noted ?at 11:05 am on 7-25-18, the facility received a call from a local hotel asking if the assisted living facility (ALF) was missing a resident with same name as resident #1. Two staff went and brought resident #1 back to the ALF?. 4. During the inspector?s interview on 7-26-18 with staff #4, who was working the front desk on the morning resident #1 left the facility, it was revealed that resident #1 was gone from the facility from around 9: 00 am until around 11:00 am. Staff #4 also stated being the one who answered the telephone call from the hotel informing the facility of resident #1?s presence in the hotel lobby.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding Personal care services and general supervision and care. A resident who is confused and demonstrating exit-seeking behavior will be provided added supervision to assure his/her safety. If the resident resides in general assisted living, the family representative and physician will be contacted to help develop an appropriate plan for ongoing safety. One-on-one supervision will be provided until the resident is able to be assessed by a health care professional and appropriate interventions can be implemented. Spring Arbor will conduct monthly Missing Resident drills to keep staff attentive to exit-seeking behaviors and proactive interventions. The Executive Director/designee will review the results of the Missing Resident Drill each month and implement additional training for team members as needed. The Regional Director will review drills each quarter to assure compliance. Compliance Date: 10/02/2018

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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