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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: Nov. 6, 2018

Complaint Related: No

Areas Reviewed:

An unannounced monitoring inspection was conducted on 11-6-18 (ar 10:15 am/dep 3:15 pm). The facility census was 68. A sample of the new admission since last inspection 3-13-18 resident records was conducted (two assisted living and one special care). Resident records were reviewed and staff interviews conducted. The acting administrator was present. The exit interview was conduct and the acknowledgement form was signed. 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. (11-17-18)

Standard #: 22VAC40-73-70-A
Description: Based on record review, document review and staff interview, the facility failed to ensure it reported to the regional licensing office within 24 hours an incident that negatively affected the life, health, safety and welfare of a resident. Evidence: 1. On 11-6-18 during a review of resident #1's record, the nurse's note dated 10-18-18 indicated resident's return to the facility. Further review of resident #1's record noted an attempt to admit to a local facility. The record also included another nurse's note indicating resident's emergency custody order (ECO) and admission to a local facility on 10-10-18. 2. The inspector's continued review of resident #1's record noted resident's aggressive behavior with both staff and resident: (a) 9-3-18 nurse's note documented resident #1's "aggressive behavior toward another resident, took doll out of another resident's hand", (b) 10-3-18 note documented resident #1, "pushing another resident down hall in a wheelchair with rapid speed, resident is also documented as hitting another resident on neck", and (c) 10-9-18 note documented resident #1, "hit another resident in face and on top of head". 3. Staff #2 confirmed the resident's aggressive behaviors with both staff and resident. Staff #2 also confirmed resident #1's admission to a local mental health facility.

Plan of Correction: It is Spring Arbor of Williamburg's policy to comply with all state regulations regarding incident reports. Resident care Supervisors In Charge (SIC) received an in-service on 24 hour Incident Reporting. Staff will be informed of when to report an incident and how to report the incident. Staff will receive information for contacting the regional licensing office. Incident Reporting In-Service held on 11/09/2018 at 2pm by Director of Quality and Education. The Resident Care Director and/or designee will be informed of each incident reported to Virginia Department of Social Service by the Supervisor in Charge and will monitor for on-going compliance.

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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