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: Aug. 21, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 Admission, Retention and Discharge 22VAC40-73 Resident Care and Related Services 22VAC40-73 Additional Requirements for Facility

Comments:

An unannounced monitoring inspection was conducted by two inspectors from the Peninsula Licensing Office. (Ar: 09:45 am/dep 5:30 pm). The facility census was 70. A review of seven residents record was conducted with facility staff. Staff provided assistance throughout the inspection and violations and technical assistance were discussed throughout the inspection process. The entrance interview was conducted with the administrator. During the exit conference with the executive director, the administrator and other representative present, the area of the standards with violations were reviewed, technical assistance provided as it related to the individualized service plan (ISP) and the grouping of assessed needs, each need should be clearly specified on the plan and reviewing the uniformed assessment instrument (uai) for clarity of assessment need category. The acknowledgement form was signed by the administrator following the exit conference. 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 (9-10-19). 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.

Violations:

Standard #:	22VAC40-73-380-B
Description:	Based on records review and staff interviews, the facility failed to ensure four of seven residents' personal and social information was kept current. Evidence: 1. On 8-21-19 during a review of the sample residents' record with staff # 2 and #3, the social data form was blank in the following areas for resident #3: (a) date of admission, (b) address, (c) special interest and hobbies and (d) current behavioral and social functioning. 2. A review of resident #4's record with staff #2 revealed the social data form did not include resident's Do Not Resuscitate (DNR) information. The resident's record included a physician signed DNR form dated 10-30-18; resident's date of admission documented as 10-26-18. 3. A review of resident #5's social data form with staff #6, the form was blank in the following areas: (a) address from which the resident was received and (b) the resident's legal representative information. 4. A review of resident #6's social data form with staff #6, the form did not include resident's DNR information. The record included a physician signed DNR document dated 5-17-19; resident date of admission documented as 5-17-19. 5. Staff #2, #3 and #6 acknowledge the aforementioned residents' social data form was blank in areas and was not updated to include current information.
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 Monitoring Inspection dated 8/21/19. 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 for the Department of Social Services and the state of Virginia. 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. 22VAC-40-73-(5)-380-B Personal and Social Data Information The Social Data Sheets for the cited residents was updated by the Health and Wellness Director/Designee by 9/6/19, based on interviews conducted with resident/responsible party where information was available. The HWD/nurse designees have been re-educated by the Executive Director on the need to fully complete all blanks in the form, leaving no blanks. In the event the resident / responsible party does not wish to share information, this choice will be listed in the blank space. An audit of all social data sheets will be conducted by the HWD/Nurse Designees/ Program Directors/Designees no later than 9.30.19 to verify that information is complete. Social Data Sheets for new move-ins will be reviewed prior to move in, by the Executive Director/ Designee, to monitor for the presence of required information with no blanks. In the event a blank is noted, the resident/responsible party will be contacted to obtain the required information or whether they choose not to share that information, and this will be noted on the form.