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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 5, 2019

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
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 3-5-19 (ar 08:30 am/dep 6:45 pm). The facility census was 69. A medication pass observation was conducted, breakfast meal was observed, staff and resident interviews were conducted, staff and resident records reviewed, facility first aid kit and emergency drills review. The new administrator and new director of nursing(resident care coordinator) was present during the inspection. An exit interview was conducted with the administrator, resident care coordinator, the special care unit coordinator, the business office manager and the new maintenance director. The acknowledgement document was signed by the administrator. Comment: The facility's resident's service plan was discussed with staff and the administrator, the new regulation which became effective 2-2018 was discussed, suggestion regarding staff review the UAI manual to determine resident's level of care and assessments, review of physician's orders and the content, need to clarify physician orders, facility's need to review its medication management plan and resident agreement for compliance with new regulation, infection control requirements allergy reaction policy per the regulation and resident council requirements for time without staff present and documentation of such. 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 (3-29-19).

Violations:
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 a major incident that negatively affected or threatens the life, health, safety, or welfare of a resident. Evidence: 1. On 3-5-19 during a review of resident #9's record with staff #5, the record indicated resident diagnosed with a stage II wound on the buttocks on 2-25-19. An physician's order for Calazine ointment to be applied. 2. Staff #3 acknowledged the incident report was not submitted to the licensing office.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding the reporting of major incidents to the Division of Licensing. Resident Care Supervisors-In-Charge and Registered Medication Aides will receive an in-service conducted by our Resident Care Director, or designee. The staff will receive information on criteria for incident reporting and required form of contacting the regional licensing office.

Standard #: 22VAC40-73-250-D
Description: Based on record review and interview the facility failed to ensure one of four staff in the record sample had an initial tuberculosis (tb) examination and report maintained at the facility and included in the staff's record. Evidence 1. On the day of the inspection (3-5-19), while reviewing the staff records with staff #1, the inspector found staff #4 hired 1-28-19, had no record of an initial tb examination and report on file. 2. Staff #1 searched the records and then confirmed no record of an initial tb examination and report was on file. During the inspector?s review of the findings, staff #1 also shared with staff #4 no record of an initial tuberculosis examination and report was located on file.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding initial tuberculosis examinations. TB examination for Staff #1 was placed on 3/20/2019 and evaluated on 3/22/2019. The community Business Office Manager or designee will ensure all newly hired team members have completed initial tuberculosis examination prior to start date.

Standard #: 22VAC40-73-320-B
Description: Based on record review, document review and staff interview, the facility failed to ensure a resident completed an annual risk assessment for tuberculosis (tb). Evidence: 1. On 3-5-19 during a review of the sampled resident's record, resident #8's record indicated the date of the last tuberculosis result was dated 2-14-18; resident #8's date of admission noted 2-16-18. 2. The licensing inspectors requested tuberculosis documentation for resident #8. Staff #10 provided the inspectors with the requested documents, however, resident #8's document indicated a date of 2-14-18. The inspector showed staff #10 the date of resident #8's tuberculosis document. Staff #8 stated that was the most current document available.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding annual risk assessments for tuberculosis for all residents. Resident #8?s risk assessment was completed on 3/5/19. A 100% audit was completed on 3/8/19 ensuring annual compliance for this standard. The community?s Resident Care Director, or designee, will complete a 100% audit bi-annually in order to ensure compliance.

Standard #: 22VAC40-73-440-D
Description: Based on record review and interview the facility failed to ensure three of nine private pay resident records reviewed in the sample had uniform assessment instruments (UAI) completed that had assessed the residents at the appropriate level of care. Evidence 1. While reviewing the resident records with staff # 3, the inspector found the following: a. Resident # 1's UAI dated 12-10-18, had the resident assessed as being dependent in bathing only. Residents assessed with no dependencies or no more than one dependency in activities of daily living shall meet the residential level of care. Resident #1 had been assessed at the assisted living level of care (dependency in two or more activities of daily living). b. Resident #2 UAI dated 2-18-19, had no dependencies in any activity of daily living. Resident #2 had been assessed at the assisted living level of care (dependency in two or more activities of daily living). c. Resident #3 UAI dated 11-8-18, had no dependencies in any activity of daily living. Resident #3 had been assessed at the assisted living level of care (dependency in two or more activities of daily living). 2. Staff #3 reviewed the UAIs and acknowledged the residents had not been assessed at the appropriate level of care.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding accurate Uniform Assessment Instrument (UAI) completion. Resident #?s 1, 2 and 3 were reassessed utilizing the UAI and correctly assessed to reflect the ?Residential Level of Care? on 3/20/19. The community?s Resident Care Director or their designee will complete a 100% audit of resident UAI assessments in order to ensure properly assessed level of care.

Standard #: 22VAC40-73-450-C
Description: Based on record review, document review and staff interview, the facility failed to ensure four of nine resident's individualized service plan (ISP) included all assessed needs. Evidence: 1. On 3-5-19 during a review of the sample resident's records with staff #3, the inspector found the following information documented on resident #6's uniformed assessment instrument (UAI) and the ISP: UAI dated 1-3-19 indicated stairclimbing need as mechanical help (mh)/human help (hh)/ physical assistance (pa); however, the ISP dated 1-3-19 did not indicate what mechanical assistance was needed or provided and it did not indicate what physical assistance was needed or provided. 2. On the same day, a review of resident #4's ISP dated 4-18-19 did not include the physician's order dated 01-10-19 for one hour of bed rest after each meal. Further review of resident #4's record included a physician's order signed 02-17-19 for no added salt (NAS) diet and cut meats, however, the ISP dated 4-18-19 indicated a regular diet. 3. On the same day of the inspection, halo restraints were observed on the bed of resident #7, however, the need was not indicated on the resident's ISP dated 10-24-18, the record also did not include a physician's order for the restraint. Further review of resident #7's record indicated the uai dated 10-24-18 indicated toileting need as mechanical help (mh)/ human help(hh)/ physical assistance (pa); however, the ISP dated 10-24-18 indicated contact guard transfer. The inspector was present in the room when the direct care staff who responded to the resident's call bell request came and requested another staff to assist. The inspector was informed resident #7 was a two person assist onto the toilet. Further review of resident #7's uai dated 10-24-18 indicated stairclimbing need as performed by others, however, the ISP dated 10-24-19 indicated unable to climb stairs, but did not indicate how the need was provided. 4. On 3-5-19, review of resident #8's uai dated 6-5-18 indicated stairclimbing need as mechanical help (mh); however, the ISP dated 7-6-18 indicated supervision of the handrails. Also the uai indicated mobility need as mechanical help (mh); however, the ISP indicated the use of a walker with staff providing reminders.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding resident?s individualized service plan (ISP) including all assessed needs. The ISP for Resident #6 was updated on 3/20/19 to reflect stairclimbing needs. Physician?s orders for Resident #4 were verified in regards to bed rest and diet. The ISP for Resident #4 was updated on 3/22/19 to reflect physician?s orders. Physician?s orders for Resident #7 were received on 3/9/19 for use of ?halo? device as a mobility aide. The ISP for Resident #7 was updated on 3/9/19 to reflect assessed mobility, transferring and stairclimbing needs. The community Resident Care Director will begin the process of becoming an ISP Trainer to develop an enhanced community knowledge of ISP completion.

Standard #: 22VAC40-73-450-F
Description: Based on record review and interview the facility failed to ensure two of nine Individualized service plans (ISP) in the record sample reviewed were updated as the condition of the resident changed. The review and update shall be performed by a qualified staff person and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other person. Evidence 1. During a review of resident #3's ISP dated 11-18-18 with staff # 3, the inspector found the resident's lactose allergy was not on the ISP. a. Also a review of resident #3?s ISP with staff #3, revealed the ISP did not include the wrist braces ordered 1-18-18 and signed 1-24-18, indicating wrist braces were to be applied at bedtime and removed in the morning. During the medication observation the resident was observed not wearing the braces. b. Staff #3 stated the order was on the medication administration record (MAR). A review of the MAR with staff #3, revealed no documentation on the MAR that staff were applying and removing the wrist braces. c. Also resident #3's ISP did not include the audiologist 1-24-19, order to clean the resident?s hearing aid daily and to monitor for wax. Staff #3 acknowledged the audiologist order was not on resident #3's ISP. 2. During a review of resident #9's record with staff #5, the ISP dated 12-10-18 was not updated to include resident #9's wound care. The nurse's note dated 2-25-19 indicated a stage 2 to the buttocks. The physician's order for wound care was signed on 2-27-19. Staff #3 was shown the wound care information in the resident's record and acknowledge the ISP was not updated to include this need.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding stakeholder inclusion in the development of Individualized Service Plans (ISP). The ISP for Resident #3 was updated on 3/5/19 to reflect allergy, wrist brace, and hearing aid maintenance. The ISP for Resident #9 was updated on 3/5/19 to reflect home health involvement in wound care. The community Resident Care Director will begin the process of becoming an ISP Trainer to develop an enhanced community knowledge of ISP completion.

Standard #: 22VAC40-73-650-B
Description: Based on record review and interview the facility failed to ensure a physician written order, for the administration of prescription medications included identified the diagnosis, condition, or specific indications for administering each drug. Evidence 1. During a review of the medication orders of resident #3 with staff # 3, the inspector found no diagnosis, condition, or specific indications for administering an eye drop. The prescription for Prednisolone1%, Gatfloxacin 0.5 % eye drops, suspension instill one drop into left eye four times a day was electronically signed on 1-16-19. 2. A review of the medication administration record for January 2019 with staff #3, listed Mucopurulent conjunctivitis as the diagnosis for the eye drops. No written physician order made available for the inspector to review on 3-5-19 listed a diagnosis. 3. Staff #3 acknowledged the 1-16-19 written order did not have a diagnosis.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding the assurance of acquiring complete physician?s orders prior to inception of treatment inclusive of diagnosis, condition and specific indications for administration. The course of treatment for Resident #3 was completed per physician?s orders. Resident Care Supervisors-In-Charge and Registered Medication Aides will receive an in-service conducted by our Resident Care Director, or designee. The staff will receive information on Spring Arbor process to ensure all physicians? orders are complete prior to treatment inception.

Standard #: 22VAC40-73-970-A
Description: Based on document review and staff interview, the facility failed to ensure the fire and emergency evacuation drill frequency and participation was conducted in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills required for each shift in a quarter shall be documented. Evidence: 1. On 3-5-19 during a check of the facility's quarterly fire drills with staff #9, the facility's monthly drill for February 2019 was not conducted. A review of the facility's documented fire drill for 12-28-18 documented staff conducted a walk thru the community, identified fire extinguishers, exit route maps, fire doors, primary and secondary meeting areas, panels. There were 7 staff members, drill took 4 minutes and no residents participated. 2. Staff #3 and #9 acknowledge the facility did not conducted monthly fire drills in December and February 2019.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding the completion of monthly fire drills. A fire drill involving residents and team members was conducted on 3/22/19 at 2:00pm. The community?s Director of Facilities, has scheduled a monthly prompt to conduct all required drills in accordance with the Virginia Statewide Fire Prevention Code and state licensing standards.

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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