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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: June 25, 2018 , July 18, 2018 and Aug. 23, 2018

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 PERSONNEL
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
The licensing inspector conducted an unannounced complaint inspection on 6-25-18; 7-18-18 and 8-23-18 in response to a complaint that was received by the licensing office on 6-19-18 and 7-18-18. Facility records were reviewed, staff interviews conducted and collateral agency staff interviews were conducted regarding allegation of resident being informed that resident would be discharged if resident cannot "stand and pivot" and resident being told to "poop in pants". The information gathered during the investigation support the allegations, so the complaint is determined to be "valid". There were other non-complaint violations resulting from this complaint investigation. 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 calendars of receipt. If you have any questions, contact the licensing inspector at (757) 439-6815. Plan of correction due 10-18-18

Violations:
Standard #: 22VAC40-73-110-1
Complaint related: Yes
Description: Based on record review and staff interview, the provider failed to ensure staff was considerate sensitive of the resident who is aged and disabled. Evidence: 1. During review of resident #1's record following complaints to the licensing office regarding resident #1 not being transferred to the bathroom timely and being told to "poop in pants", the licensing inspector?s (LI) review of the facility?s document entitled, "Level of Care Assessment ADL needs Checklist" for billing noted the ?resident?s level of care total score 24. The same document indicated toileting with a score of 3, transferring score of 3 (X 2-score double to 6, two-person assist score of 5. The score numbers noted the following: 3 or 4 points?..extensive assistance ( weight bearing support from another person?someone else to perform task for him/her) and 5 points-Totally dependent?someone else must complete the task for the resident at all times?staff manage incontinency?resident unable to walk, with or without assistive device or a resident?? 2. On 6-25-18, during interview with staff #2, the LI, inquired of staff if resident was told to poop in pants, staff #2 stated resident #1 ?could go the bathroom but was choosing to not go. The resident was also using the depends when the resident was first admitted, but have become difficult for staff and not wanting staff to check on resident #1 during the night. The resident did not want to be disturbed during the night.? 3. On 6-25-18 during a review of resident #1?s uniformed assessment instrument (UAI) dated 5-11-18, 5-17-18 and 6-16-18 with staff #2, the UAI indicated resident #1 toileting need was assessed as mechanical help/human help/physical assistance (mh/hh/pa) and bowel assessed as not needing assistance. The UAI also indicated transferring assessed as mh/hh/pa; walking not performed, mobility with motorized wheelchair. A review of the resident?s physical dated 5-15-18, the ?brief history? noted on the attached ? Current Outpatient prescriptions? indicated resident noted to have ?impaired gait and inability to ambulate? and the resident ?discharge orders dated 5-16-18? indicated resident ?impaired gait and mobility, at high risk for falls, and weakness of limb, muscle weakness and idiopathic peripheral neuropathy.? 4. On 6-25-18, during the LI?s interview with resident #1, resident stated needing assistance going to the toilet and also stated using a sliding board to transfer on and off the toilet. Resident #1 stated ?there was often delays in getting to the restroom because some staff would come and inquire what was needed, if resident needed to use the restroom, some staff would assist with transferring without another staff and some would say they needed to get help.? Resident #1 stated ?staff would take too long to return and resident would end up having a bowel movement in the adult depends that is used to assist with urination. This was uncomfortable and not dignified to sit in the wheelchair in this condition, sometimes pants would get soiled.? 5. During LI?s interview with staff #6, staff stated ?changing resident #1 on the bed, resident not safe to be on toilet.? Also staff #9, on 7-15-18 presented a note to staff #1, indicating assisting staff with changing resident #1 in the bed.? 6. On 7-25-18 and 8-23-18 during the LI?s interview with staff #1, and resident #1?s dignity concern, regarding ?pooping in pants?, staff #1 stated ?resident was using the depends when the resident first came and there was no issue.? The LI reminded staff #1, that the complaint to the licensing office was regarding the issue of the resident having to ?poop in pants?. The LI also showed staff #1, the facility?s UAI which indicated the resident was assessed as independent with bowel (continent) and incontinent with bladder and needing assistance with transferring to toilet.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to abide by all Virginia Department of Social Services regulations regarding respecting residents. Staff received an in-service on October 19, 2018 regarding consideration and respect for the rights, dignity, and sensitivities of persons who are aged, infirmed, or disabled. The Executive Director and/or designee will ensure all staff receive annual training regarding Residents Rights and Responsibilities for compliance. Date completed: 10/19/2018

Standard #: 22VAC40-73-440-A
Complaint related: Yes
Description: Based on record review and staff interview, the provider failed to ensure the resident to the assisted living was assessed face to face using the uniform assessment instrument. Evidence: 1. During the licensing inspector's (LI) interview with staff #2, on 6-25-18 regarding a complaint of resident #1's "being informed that if resident could not 'stand and pivot' resident would have to be discharged from facility", staff #2 was asked if resident could "stand and pivot" prior to admission. Staff #2 stated, "staff #2 did not conduct a face to face assessment of resident #1; staff #2 stated "reviewing resident's record at the discharging facility and an interview was conducted with resident #1". 2. A review of resident #1's record with staff #2 on 6-25-18 revealed resident's admission UAI dated 5-11-18 and indicated walking was not performed.

Plan of Correction: No response received from provider

Standard #: 22VAC40-73-450-C
Complaint related: Yes
Description: Based on record review and staff interview, the provider failed to ensure the resident's individualized service plan (ISP) included resident's assessed needs. Evidence: 1. On 7-18-18, during the licensing inspector's (LI) interview with staff #1, it was revealed that resident #1's uniformed assessment instrument (UAI) dated 5-11-18, 5-17-18 and 6-16-18 indicated bowel and need no assistance. However, the individualized service plan (ISP) dated 6-16-18 indicated "depends are worn for protection....staff provider perineal care after a bowel movement"; person who will provide service, resident box is checked and service to be provided in bathroom. The ISP also indicated under the bowel description of need and date identified, need date of 5-17-18 and "if incontinent: family or vendor will be notified to provide & maintain supply of incontinent products". The ISP also indicated, "depends...supplied by the family". 2. Staff #1, confirmed the UAI indicated the resident was continent of bowel, but the ISP indicated the resident required assistance and wore depends for protection.

Plan of Correction: No response received from provider

Standard #: 22VAC40-73-450-E
Complaint related: No
Description: Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or the legal representative for a resident. Evidence: 1. On 6-25-18 during a review of the resident #1's ISP with staff #2, the ISP dated 6-16-18 did not include the resident's signature nor the resident's legal representative's signature and date. 2. On 7-18-18, during inspector's interview with staff #, staff #1 also confirmed resident #1's ISP dated 6-16-18 was not signed by the resident nor legal representative.

Plan of Correction: No response received from provider

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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