VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Chambrel Williamsburg
3800 TREYBURN DRIVE
Williamsburg, VA 23185
(757) 220-1839

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-120-C
Description:	Based on record review, document review and staff interview, the facility failed to ensure during orientation, a staff was trained in all of the required facility?s policies and procedures. Evidence: 1. On 5-8-19 during the inspector?s review of staff records with staff # 6 the inspector requested to see staff # 7's documentation of review of the resident?s rights and responsibilities. Staff # 7 presented the inspector a copy of ?Rights and Responsibilities of Residents of Assisted Living Facilities? document. Upon inspection of the document, the inspector did not see a date or signature. The staff was hire 4-25-19. 2. Staff # 7 acknowledged the document was blank, and did not include a signature or date of review .
Plan of Correction:	1) A review of Resident?s Rights will be completed by the Executive Director/ Designee with all staff by June 24th, 2019. 2) Our e-learning system will be updated to accurately meet the requirements of this standard, and will auto-assign the required courses to each student. Until that time, we will use paper to document initial, and annual, resident right reviews. 3) The Executive Director (ED)/Designee will be responsible for oversight of the Resident Rights training, and will be responsible for assigning of Resident Rights training through the e-learning system or in person ongoing.
Standard #:	22VAC40-73-210-F
Description:	Based on record review, document review and staff interview, the facility failed to ensure a staff training documentation included at least two of the required hours of training on infection control and prevention. When adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to residents' mental impairments. Evidence: 1. On 5-7-19 and 5-8-19 during the inspector?s review of staff record with staff # 8 and staff # 6, it was revealed that staff # 9's electronic training record listed 3 of the 4 hours of mental health training required annually. A review of the facility?s required 2 hour infection control training conducted by staff # 10, did not include staff #9's name on the sign-in roster. 2. Staff #6 and # 10 acknowledged staff # 9 did not have the required 2 hours of infection control or the 4 hours of mental health training.
Plan of Correction:	The computerized learning system will be updated to ensure that all required hours of training are included. Until the system is updated training will be documented on paper. 2). The Human Resources Director will alert department heads weekly of trainings completed through the computer learning system to ensure that required training hours are current.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview the facility failed to ensure two of five staff records reviewed included the required staff health information. A staff did not have an annual evaluation of a TB risk assessment documenting the individual was free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Another staff had a risk assessment older than 30 days. Evidence 1. While reviewing staff records with staff # 1 , the inspector found staff #1's last TB risk assessment on file was dated 9-6-17. 2. During the inspection, staff #1 searched the file but could not find documentation of any other TB risk assessment on file. 3. On 5-7-19 during the inspector?s review of staff record with staff # 8 and staff # 6, the risk assessment observed in staff #6's record was dated 9-21-18. Staff # 6 date of hire was noted 10-29-18. 4. Staff # 6 stated, ?I thought the document was transferable?, and acknowledged the document was older than 30 days.
Plan of Correction:	1). TB Risk Assessments for current staff will be reviewed and updated by the HWD/Designee as needed by June 24th, 2019. TB risk assessments for current residents will be updated annually during the month of May. 2). Human Resources Director/ Designee will audit four files per month for 3 months, then periodically as needed to monitor for ongoing compliance. 3) Audit findings will be reported to the ED/Designee who will be responsible for directing additional audits as needed in an ongoing manner.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it Evidence 1. While reviewing the record on a recent admission on the secure unit with staff #1 , the inspector found resident #5 admitted 1-18-19 had a physical examination dated 1-11-19; however the examination did not include a risk assessment documenting the absence of tuberculosis in a communicable form. The inspector observed a TB form on file with no date, no results and no documentation as to what type of screening and test was performed. 2. Staff #1 acknowledged the TB form did not include the required information.
Plan of Correction:	1). Current resident charts will be audited to ensure that all required elements have been completed, including a TB Screening with appropriate information. 2). Prior to resident move in, all physical examinations will be examined by the Health and Wellness Director or her designee to ensure that all required elements have been completed, including a TB Screening with appropriate information.
Standard #:	22VAC40-73-325-B
Description:	Based on record review and interview the facility failed to ensure one of five residents in the record sample had a fall risk rating reviewed and updated under the following circumstance: After a fall. Evidence 1. During a review of the residents records with staff #1 , the inspector found resident #2's last fall risk observed on file was dated 2-1-19. A review of the record revealed on 3-9-19, resident #2 was found on the floor on her knees leaning against the bed . No fall risk rating had been completed subsequent to the resident being found on the floor. 2. Staff #1 acknowledged there was not another fall risk rating completed after the 2-1-19 rating.
Plan of Correction:	An audit of current charts will be completed by the HWD/Designees to verify Fall Risk Rating is accurate, no later than June 24th, 2019. 2). Fall Risk Evaluations will be completed on new residents and on current residents after a fall. 3). The Health and Wellness Directors/designees will audit four fall risk ratings per month to monitor for ongoing compliance. Additional monitoring will be at the direction of the HWD/Designee based on audit findings.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, document review and staff interview, the facility failed to ascertain, prior to admission, whether potential residents were registered sex offenders and document in the residents' record that this was ascertained and the date the information was obtained for two of five residents in the record sample. Evidence: 1. On 5-7-19 during the inspector?s review of residents? record with staff # 7and # 10, the inspector found resident # 6's sex offender document was dated 2-19-19; the resident?s date of admission was 2-15-19. 2. A review of resident # 7's record with staff # 10, revealed the resident?s sex offender document was dated 12-21-18; resident?s date of admission was 12-20-18. 3. Staff # 10 acknowledged the sex offender documents were completed after admission.
Plan of Correction:	1). Current resident charts will be audited by the HWD/Designees no later than June 24th to verify Sex Offender Screenings are in place. 2). The Assisted Living and Clare Bridge Directors will audit all pending admission files to ensure that Sex Offender Screenings are in place prior to move in. 3). Audit findings will be reported to the Executive Director/Designee, who will be responsible for additional corrective action, based on audit findings.
Standard #:	22VAC40-73-440-D
Description:	Based on record review, document review and staff interview, the facility failed to ensure the uniformed assessment instrument (UAI) was completed as required by 22 VAC 30-110 for private pay resident. Evidence: 1. On 5-7-19 during a review of residents? record with staff # 7 and staff # 10, resident # 8's UAI dated 2-8-19 and 3-8-19 noted no activities of daily living (ADL) dependency . However, resident # 10 was assessed at assisted living level of care. Further review of resident # 10's UAI noted the signature for the assessor and the reviewer was staff # 6. 2. A review of resident # 6's UAI dated 2-8-19 and 3-8-19 did not include the resident?s assessed level of care. 3. Staff # 6 acknowledged the UAI was not completed as required.
Plan of Correction:	).Current resident UAIs will be reviewed for accuracy by the HWD and Designees prior to June 24th, 2019, and updated as necessary.. 2). Health and Wellness Directors/designees, will audit four UAIs per month to ensure ongoing compliance. 3). These audits will be performed monthly for 3 months, at which time the HWD/Designee will make a determination for the frequency of additional audits, based on audit findings.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, document review and staff interview the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs of the resident. Evidence: 1. On 5-7-19 during a review of the residents? record with staff # 10 and staff # 6, resident # 7's ISP signed by the resident on 1-10-19 and 4-8-19 did not include the resident?s physical therapy services. Resident # 7's admitting physical examination dated 12-17-18 included an order for physical therapy. 2. The inspector?s interview with staff # 10, revealed resident # 7) participated in therapy services . Further review of resident # 7's record revealed the resident had a pacemaker, but this was not included on the ISP. 3. A review of resident # 6's ISP with staff # 7 and staff # 10 on 5-7-19, revealed the resident?s ISP dated 3-10-19 did not include the resident's physical therapy and occupational therapy services. The resident?s admitting physical examination dated 2-12-19 noted therapy services for unsteady gait; and a physician order dated 2-21-19, indicated physical and occupational therapy due to recent fall. 4. A review of resident # 9's ISP dated 5-15-18 and resident # 6's ISP dated 3-8-19 noted wheeling not performed. A review of the residents? ISPs did not include what services staff would provide to assist the residents. 5. Staff # 10 and staff # 6 acknowledged the ISP did not include all of the residents assessed needs.
Plan of Correction:	The following is a summary of the Plan of Correction for Brookdale Williamsburg. This Plan of Correction is in regards to the Violation Notice dated May 7th and 8th, 2019. This plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. 1). The District Director of Clinical Services has re-educated the Health and Wellness Directors in completing Individual Service Plans and the Uniform Instrument Assessment. This training was completed on May 9, 2019. 2). An Audit of current residents? Individual Service Plans will be completed by the Health and Wellness Directors (HWD)/ designees, to verify accuracy no later than June 24th, 2019. Necessary updates, if needed, will be completed at the time of each audit. 3).To assist with monitoring of ongoing compliance, the Health & Wellness Directors/designees will perform four ISP audits each month to verify compliance goals in accuracy of Individual Service Plans. These audits will be performed monthly for 3 months, at which time the HWD/Designee will make a determination for the frequency of additional audits, based on audit findings
Standard #:	22VAC40-73-450-E
Description:	Based on record review, document review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan. Evidence: 1.On 5-7-18 during the inspector?s review of residents? record with staff # 7, resident # 8's ISP signed by the resident on 3-10-19 did not include the date the plan was completed by the developer. 2. A review of resident # 6's record with staff # 7 and staff #10 revealed resident # 6's ISP dated 3-10-19 by the resident, did not include the date and signature of the developer of the plan. 3. Staff # 1 staff # 7 and staff # 10 acknowledged the ISPs were not signed and dated as required per the regulation.
Plan of Correction:	1). The District Director of Clinical Services has re-educated the Health and Wellness Directors in completing Individual Service Plans and the Uniform Instrument Assessment. This training was completed on May 9, 2019. 2). An Audit of current Individual Service Plans will be completed by the Health and Wellness Directors/ designees, and monitored for accuracy no later than June 24th, 2019. 3).To assist with monitoring of ongoing compliance, the Health & Wellness Directors/designees will perform four audits each month to review the accuracy of Individual Service Plans. These audits will be performed monthly for 3 months, at which time the HWD/Designee will make a determination for directing the frequency of additional audits, based on audit findings.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview the facility failed to ensure three of the five secured unit residents in the record sample had individualized service plans(ISPs) updated as the condition of the residents changed. The updates 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 persons. Evidence 1. During a review of the resident records with staff #1 , the inspector found the following : a. resident #2's ISP dated 1-10-19 did not address the bladder and behavior dependencies noted on the 12-1-18 uniform assessment instrument, the inspector also reviewed psych notes dated 3-25-19 indicating the resident may hit, kick, bite and had diminished social skills. The ISP had not been updated to reflect the changes. b. resident #3's ISP dated 3-11-19, had not been updated to reflect the psych services received ,the inspector reviewed psych notes on file dated 3-25-19, 4-3-19, and 4-9-19 c. resident # 5's ISP dated 1-23-19, had not been updated to include the resident's behaviors involving her incontinency ,the inspector reviewed notes dated 4-7-19 and 4-11-19 about inappropriate disposal of briefs in trash cans and a 4-6-19 note about leaving briefs in the shower , the inspector also reviewed a note dated 4-3-19 about the resident resisting incontinent care 2. Staff #1 acknowledged the ISP had not been updated to reflect the changes.
Plan of Correction:	1). The District Director of Clinical Services has re-educated the Health and Wellness Director in completing Individual Service Plans and Uniform Instrument Assessment. This training was provided on May 9, 2019. 2). An Audit of current residents? Individual Service Plans will be completed by the Health and Wellness Directors/ designees to verify accuracy no later than June 24th, 2019. 3).To assist with monitoring of ongoing compliance, the Health & Wellness Directors/designees will perform four audits each month to verify compliance with accuracy of Individual Service Plans. These audits will be performed monthly for 3 months, at which time the HWD/Designee will make a determination for the frequency of additional audits, based on audit findings.
Standard #:	22VAC40-73-450-H
Description:	Based on observation , record review , and interview the facility failed to ensure a specified care and service in the individualized service plan was provided to one of five residents in the secured unit record sample. Evidence 1.While reviewing the resident records with staff # 1, the inspector found documentation indicating resident #2 wears hipsters as an intervention for frequent falls. During the facility tour with staff #1, the inspector observed a pair of hipsters drying on the towel bar in resident #2's bathroom. Staff # 1 stated "the resident has two pairs of hipsters". 2. The resident's ISP dated 1-10-19, indicated the hipsters will be put on daily in the morning during morning care . During interview the inspector was told hospice staff provides the morning care and puts on the hipsters. 3. After lunch staff #2 and #3 assisted resident # 2 with toileting . Later the inspector was told in the presence of staff #1 , resident # 2 did not have on the hipsters.. 4. The hipsters had not been put on during morning care as specified in the 1-10-19 ISP.
Plan of Correction:	1). The LPN on each shift has been designated to monitor for the use of, and document, that resident #2 has on hipsters. 2). Hospice staff has been educated by the Health and Wellness Director (HWD)/Designee of resident?s need for hipsters and the importance of collaboration with the caregivers and nurses regarding residents? Individual Service Plans. This training was completed on May 23, 2019. 3). Hospice staff will be required to review and sign each Individual Service Plan of residents they provide care for, no later than June 24th, 2019. The HWD/Designee will be responsible for monitoring of Hospice services in collaboration with the Hospice provider.
Standard #:	22VAC40-73-970-E
Description:	Based on record review and interview the facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents participating; the time it took to complete the drill; and the method used for notification of the drill. Evidence 1. During a review of the fie drill records with staff # 1 , the inspector found the record of the fire drills did not include how long the drill took, the number of residents participating or the method of notification of the drill. 2. Staff #1 confirm the documentation on file did not include the number of residents participating , the method of notification or the time it took to complete the drill.
Plan of Correction:	1). The Maintenance Director has been re-educated by licensed administrator on the information required for all fire drills. This training was completed on May 9, 2019. 2). The community will be begin using the state model form for fire drills to ensure we are capturing all of the required information. 3). The Maintenance Director/Designee will be responsible for providing the Executive Director with copies of all Fire Drill Documentation to monitor for compliance.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and interview the facility failed to ensure a complete first aid kit was on hand in each building and located in a designated place that is easily accessible to staff but not to residents. Items with expiration dates must not have dates that have already passed. The kit shall include the following items: Antiseptic wipes or ointment; Hand cleaner Evidence 1. During a check of the secured unit first aid kit with staff #4 and in the presence of staff #1 , the inspector found the documented last check of the kit was 5 -2019 . The inspector observed a box of antiseptic wipes that had expired 12-2016 and a bottle of hand sanitizer that had expired 10- 2018 in the first aid kit . 2. Staff #4 confirmed the antiseptic wipes and the hand sanitizer had expired.
Plan of Correction:	1). All First Aid Kits have been monitored for compliance. 2). First Aid Check Off list will have expiration dates added to the list added to guide the auditor on the required contents and to monitor for ongoing compliance. 3) The HWD or Designee will be responsible for monthly audits of all first aid kits to verify the necessary equipment is present and that expiration dates are noted.