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: Sept. 9, 2019 , Sept. 10, 2019 and Sept. 11, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73- Administration and Administrative Services 22VAC40-73- Personnel 22VAC40-73 -Staff and Supervision 22VAC40-73- Admission, Retention and Discharge 22VAC40-73- Resident Care and Related Services 22VAC40-73- Resident Accommodations and Related Provisions 22VAC40-73- Buildings and Grounds 22VAC40-73- Emergency Preparedness 22VAC40-73- Additional Requirements Facility with Serious Cognitive Impairments 63.2- (16)- Protection of adults and reporting 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 Sworn Statement or Affirmation 22VAC40-90 Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted with two inspectors from the Peninsula Licensing Office: 9-9-19, day 1(ar 08:22/dep 6:55 pm); 9-10-19, day 2 (at 8:00am/dep 5:45 pm) and one inspector on 9-11-19, day 3 (at 10:20 am/dep 4:55 pm). The facility census was70. A medication pass observation was conducted, staff and resident interviews, tour of the facility, staff and resident record reviews conducted; breakfast meal observed in building II; first aid kits were checked, emergency preparedness items reviewed; resident council minutes reviewed, activity observed and emergency documents reviewed. The violations and technical assistance reviewed throughout the course of the entire inspection. An exit interview was conducted with facility team members on all three days. The administrator of record signed the acknowledgement form all three days of the inspection. Comments: Facility reminded the time of meals should be posted for the residents to see; meals posted should be served with substitutions noted and kept for two years. Suggest medication time may need to be adjusted so that staff can administer medications within the window (building I). 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 ,10-1-19. 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 #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interview, the facility failed to ensure staff was in compliance with procedures for blood glucose practices that are consistent with CDC recommendations for a resident. Evidence: 1. During the medication pass observation staff #8 was observed placing resident #9?s glucometer on the dresser in the room Staff #8 was later observed placing the glucometer on the resident?s bed following obtaining the finger stick. Staff #8 was observed returning the glucometer and storage case to the storage compartment of resident #9?s rollator walker located in the kitchen area of the apartment. The glucometer and the storage case was observed were not labeled with the resident's name. 2. Staff #9 acknowledged resident # 9's glucometer and storage case were unlabeled; no barrier or cleansing of the surface was conducted to the surfaces where the glucometer was placed during the blood glucose finger stick process.
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 September 9th, 10th and 11th. This plan of Correction is not to be construed as an admission of or agreement with the findings and conclusion 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. Resident #9's glucometer has been disinfected, labeled with the resident's name, and will be stored on the medication cart. 2. Re-education will be conducted by the Health and Wellness Director (HWD)/Nurse Designee to licensed and registered staff members on the appropriate storage, labeling and proper infection control procedures for residents with glucometers no later than 10/31/19. 3. The med cart will be audited by the Health and Wellness Director / designee monthly ongoing to monitor for compliance with storage and appropriate labeling of glucometers. Observations of resident blood sugar monitoring will be conducted by the Health and Wellness Director / designee weekly for one (1) month. 4. To assist with ongoing compliance random medication pass observations and monitoring of blood sugar infection control procedures will be conducted by the Health and Wellness Director/ designee for (3) months.
Standard #:	22VAC40-73-120-A
Description:	Based on record review and staff interview, the facility failed to ensure orientation was completed within the first seven working days of employment for one of five staff. Evidence: 1. On 9-11-19 during a review of staff #9's record with staff #11 and #1 it was revealed that staff #9 's orientation document was not signed and dated by staff acknowledging completion of orientation. 2. Staff #1 and #11 acknowledged the orientation document was not signed by staff #9.
Plan of Correction:	1. Unable to retroactively correct the acknowledgment of orientation completion for staff member # 9, 11 and 1. 2. An audit was conducted to verify current associates have a completed orientation on file. Re-education regarding the requirement to complete associate orientations within the first seven days of employment, will be provided to the Human Resources Director, Executive Directors and Health and Wellness Directors by the District Director of Clinical Services/Designee no later than 10/31/19. 3. New hired associates will have a signed and dated acknowledgement that they completed orientation within 7 working days of employment. Completed 9/20/2019. 4. Audits will be done by the Human Resources Director / designee of all new hires monthly, for four (4) months, to assist with ongoing compliance.
Standard #:	22VAC40-73-250-C
Description:	Based on record review and staff interview, the facility failed to ensure one of five staff record included verification of receipt of his job description. Evidence: 1. During a review of staff #9's record with staff # 11,staff #9 was first hired as direct care staff, date of hire 6-17-19. However, the record did not include a copy of staff #9's job description. According to staff #1, staff #9 was later hired as licensed practical nurse (LPN) upon passing the exam. However, the record did not indicate a change in job description and nor date of the job change from certified nurse's aide to licensed practical nurse. The record did contain a copy of the signed job description for a nurse and a copy of the verification of staff #9 multistate license to practice as an LPN. 2. Staff # 11and #1 acknowledge staff #'s record did not include signed job description for direct care staff.
Plan of Correction:	1. Staff # 9 has signed the appropriate job description. 2. An audit of associate files was conducted by the HR Director/Designee to verify other associates have the appropriate job description signed and placed in the associate file. This was completed on 9/11/19. 3. Re-education by the District Director of Clinical Services/designee to the Human Resources Director will be completed no later than 10/31/19. 4. An audit by the Human Resources Director/ designee will be completed of ten (10) staff records, including new hires, weekly for four (4) weeks. 5. Thereafter, to assist with ongoing compliance the Human Resource Director/designee will be responsible for completing monthly, for four (4) months, audits of staff records and notifying the ED/designee with the results. The ED/designee will direct any additional actions based on the audit findings.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, document review and staff review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form for four of five staff. Evidence: 1. On 9-11-19 during a review of staff record with staff #11, the following staff?s tuberculosis(tb) indicating staff was free of tb in a communicable form was completed after the date of hire: (a) staff #1- date of hire 10-29-18; date of tb result dated 10-31-18; (b) staff #3- date of hire 6-3-19; date of tb result dated 6-5-19; (c) staff #8- date of hire 12-12-18; date of tb result dated 12-14-18 and (d) staff #9- date of hire 6-17-19; date of tb result 6-19-19. 2. Staff #1 and #11 acknowledge the results of staff tb was after the date of hire. 3.Staff #1 and #5 was inquired of the facility?s policy regarding staff tb. The inspector requested a copy of the facility's policy for staff tuberculosis.
Plan of Correction:	1. Unable to retroactively correct staff members # 11, 1, 3 and 8 tuberculosis completion dates. 2. The HR Director/Designee will be re-educated by the ED/designee regarding the state requirement for TB testing and the appropriate timeframe for completion. This re-education will be completed no late than 10/15/2019. 3. Audits will be completed monthly for four (4) weeks to verify documentation of the absence of tuberculosis in the communicable form dated within seven ( 7 ) days prior to the first day of work are in the staff records All new hires are now tested/screened for tuberculosis when initial drug and criminal backgrounds are conducted to ensure new hires are free of tuberculosis in the communicable form prior to first day of work-completed 9/11/2019. 4. To assist with ongoing compliance the Human Resource Director/designee will conduct audits monthly for four (4) months.
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interview, the facility failed to ensure the list of staff with first aid and cardiopulmonary resuscitation (CPR) was posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. On 9-10-19, a request was made of staff #9 in ALF II building to view the first aid and CPR posting. Staff and the inspector looked in the locked medication storage area, the staff lounge and the nurse?s station. Staff #9 was asked if the document could be posted anywhere else in the building, staff did not know. 2. Staff acknowledged not knowing where the first aid and CPR posting was located in the ALF-II building.
Plan of Correction:	1. A list of staff with current First Aid and cardiopulmonary resuscitation (CPS) training is available to all staff. Completion Date 9/11/2019. 2. The HR director/designee will audit associate files to determine expiration dates for CPR and First Aid certifications, and will provide the master list to the supervisor of each department on a monthly basis. The ED will re-educate the AL Director and the HR Director on the posting requirement and the need to keep an updated list, no later than 10/31/19. 3. An audit will be conducted monthly by the Human Resource Director to verify the list is current and accurate. 4. To assist with ongoing compliance the Human Resource Director/Assisted Living Director will conduct monthly audits, for four (4) months, of CPR certifications and First Aid expiration date and provide such documentation to the Ed and AED, who will be responsible for directing further action required in order to maintain compliance.
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interview, the facility failed to ensure the name of the current on-site-person in charge was posted as required per the regulation. Evidence: 1. On 9-9-19, when the inspectors arrived at 08:22 a.m. in the ALF-I building, the inspectors did not see the posted name of the staff person in charge. The inspectors went to the nursing station and inquired of staff #6, who was in charge. Staff #6 stated being in charge. 2.Staff #6 acknowledged the name of the staff person in charge for the morning and previous night shift (11pm-7 am) was not posted.
Plan of Correction:	1. The Assisted Living Director/designee posted the name of the on-site designated person in charge in a public area. Completed 9/11/19. 2. Executive Directors (ED) and Health and Wellness Directors (HWDs) will receive re-education from the District Director of Clinical Services regarding the requirement that the on-site Person in Charge must be posted as required under VA regulations. This re-training will be provided no later than 10/15/19. 2. Compliance with posting will be monitored daily on all shifts for one (1) week by the Executive Director / designee. 3. To assist with ongoing compliance, the Assisted Living Executive Director/designee will conduct weekly reviews for one (1) month.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the provider failed to ensure it did not retain an individual with psychotropic medications without appropriate treatment plans for one of twelve resident. Evidence: 1.On 9-10-19 during a review of residents? record on the special care unit with staff # 5 and #6, resident #5?s record did not have documentation of a psychotropic treatment plan. Resident #5 prescribed the following psychotropic medications: (a) Seroquel, (b) Trazadone and (c) Buspirone. Further review of the record noted resident #5 was admitted on 8-22-19. 2.Staff #5 and #6 acknowledged resident #5?s record did not include a treatment plan for the aforementioned psychotropic medications.
Plan of Correction:	1. For Resident #5, community was unable to retroactively correct the psychotropic medication plan for resident # 5. 2. The Executive Directors (ED) and Health and Wellness Directors (HWDs) will receive re-education from the District Director of Clinical Services regarding the requirement that individuals with psychotropic medications may not be retained without an appropriate treatment plan. This re-training will be provided no later than 10/15/19. 3. An audit will be conducted no later than 10/21/19 by the HWD/designee to verify all current residents receiving psychotropic medications will have a psychotropic medication plan developed no later than the day of admission. 4. HWD/designee will review all residents receiving psychotropic medications quarterly, with the first review completed on 9/11/2019, for one (1) year.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure all assessed needs for a resident was included on the individualized service plan (ISP). Evidence: 1. The facility documentation showed resident #3 was admitted to the facility's safe, secure unit on 8/16/2019. Based on statements from staff #3, the resident had a brain injury and had a history of isolation. The facility's face sheet noted resident's diagnosis of Major Depressive Disorder and Unspecified Mood "Affective" Disorder. Resident #3's ISP identified the resident's behavior pattern date on 8/16/19. However, the description of services needed noted "Resident's behavior is appropriate. Staff to notify HWD of any change in this status." The facility did not address the need to monitor for the diagnosis of Major Depressive Disorder or Unspecified Mood "Affective Disorder." 2. Staff #2 acknowledge the ISP did not address resident's psychiatric diagnosis and how facility would meet need or monitor resident for changes.
Plan of Correction:	1. Resident #3 has been evaluated by the medical physician. A diagnosis of "dementia with cognitive impairment" has been added. Residents with a psychiatric diagnosis will have the identified need place on the Individualized Service Plan. This will include how the need will be met or monitored for any changes. Completion date 10/15/2019. 2. Re-education regarding the need to verify all assessed needs are included on the ISP will be conducted by the District Director of Clinical Services/designee will be conducted to the Assisted Living and Clare Bridge Directors , and the Health and Wellness Directors no later than 10/31/19. 3. New Admission and two (2) additional charts weekly for four (4) weeks will be completed by the Executive Director/ Health and Wellness Director /designee to verify an appropriate diagnosis for the secured unit is present and all information is correctly address on the ISP. 4. To assist with ongoing compliance the Executive Direct/ Health and Wellness Director/ designee will conduct chart audits before any referral is placed on the secured unit..
Standard #:	22VAC40-73-580-B
Description:	Based on record review and staff interview, the facility failed to ensure a resident on the safe, secure environment, who eats in room and have a psychiatric diagnosis had an assessment by a qualified mental health professional regarding meals choice in room. Evidence: 1. Based on facility documentation resident #3 was admitted to the facility secure unit on 8/16/2019. Resident face sheet provided by the facility shows diagnosis of Major Depressive Disorder and Unspecified Mood "Affective" Disorder. Based on resident #3's "meal consumption record" resident#3 had received tray services in the apartment during the dates of September 1, 2019 to September 8, 2019 a total of 21 out of 24 times. Based on statements provided by staff #2, Resident #3 had a history of isolation and the resident did not like to eat meals in the dining room nor participate in activities. Licensing Inspector attempted to interview resident #3 with staff #5. Resident #3 requested the Licensing inspector to wait and staff #2 went in and out of the room informing the inspector that resident #3 was getting dressed and ready. After staff #2 went in and out of the apartment 3 times with a different answer provided by resident #3, the Licencing Inspector ended attempts to interview resident. When reviewing resident #3's record the resident did not have a written agreement signed and dated by both the resident and the licensee or administrator filed in the residents record. 2. Staff #1 and #2 acknowledged Resident #3 did not have a determination by a qualified mental health professional in writing whether the resident should have the option of having meal in the room.
Plan of Correction:	1. Resident #3 has been evaluated by her Medical Physician (Policy currently states Mental Health Professional) and a letter placed on file regarding her preferences for receiving meals in her room. The Assisted Living Director will have a written documentation between the executive director and resident allowing their preference to take meals in their room, and will included discussion of the risks and benefits of these choices. It will be signed, dated and filed in the resident's records, and will be reviewed semi-annually by all parties, to verify appropriateness. 2. An audit was conducted of all current residents taking meals in their room on 9/30/19. The required agreements will be verified for placement in the resident's record and the specific needs identified on the individualized service plan will be addressed as indicated by the Medical Physician. The appropriate associates will be re-educated on the Room Tray Policy and the need to notify ED or HWD when a r3sident requests room trays, in order to assist with compliance of the policy. 3. The Assisted Living Director/designee will audit room service requests weekly for four (4) weeks. 4. To assist with ongoing compliance random chart audits will be conducted by the Executive Director/ designee monthly for four (4) months.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the provider failed to ensure a physician or prescriber order for a prescription identified the diagnosis, condition, or specific indications for a drug for a resident. Evidence: 1. On 9-9-19 during a review of residents? record with staff #1 and #2, a review of resident #1?s physician?s order dated 9-3-19 did not include a diagnosis for resident's Methadone. 2. Staff #2 acknowledged the physician?s order for the aforementioned drug did not include a diagnosis.
Plan of Correction:	1. The diagnosis for resident #1 Methadone has been obtained and added to the Physician order sheet. 2. An audit of physician orders has been completed by the HWD/designee to verify medications have a corresponding diagnosis. 3. Nursed have been re-educated on the need to verify that all new orders have a corresponding diagnosis or directions for use. This training will be conducted by the District Director of Clinical Services or Nurse Designee no later than 10/31/19. 4. The New Order tracking sheet will be utilized to verify all new orders have the required information. An audit of new orders will be done weekly for four (4) weeks, by the Health and Wellness Director/ designee to verify compliance. 5. Thereafter, to assist with ongoing compliance the Health & Wellness Director/designee will conduct the monthly audits of Point Click Care reports, for four (4).
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interview, the facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees (F). Evidence: 1. On 9-9-19 during a tour of ALF Building II with staff #12, the water temperature on the first floor common area bathroom had a reading of 127.8 degrees (F). The temperature in room #318 had a reading of 129.2 degrees (F). 2. Staff #12 acknowledged the temperatures aforementioned were above the regulation requirement.
Plan of Correction:	1. The water temperature was adjusted to within normal range-compliance date 9/11/2019. 2. Water temperatures will be checked in AL1, AL2 and Clare Bridge three (3) times weekly, for one (1) month. They will be logged into the maintenance tracking system. 3. to assist with ongoing compliance, the Maintenance Director/designee will conduct water temperature checks monthly for four (4) months.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviews, the facility failed to ensure the signaling and call system was operable. Evidence: 1. On 9-9-19 during a tour of the ALF II building, the signaling and call system on the safe, secure environment was not working. The call system was pulled in room #318 at approximately 11:45 am and there was no staff response by approximately 11:57am and no response from the concierge's desk. 2. Staff spoke with staff on the unit who stated their pagers did not ring. Staff #12 and #1 were informed and staff #12 acknowledge the system was not reading to the staff pagers.
Plan of Correction:	1. The antennae was replaced on AL2 for the signaling/call system on 10/2/219. Random room checks were done to ensure the new antennae was sending the signal properly 2. The signal is sent to the main concierge desk, and the concierge on duty 24/7 calls over to the building receiving the call to ensure it is answered in a timely manner. 3. The Maintenance Director/designee will audit 4 random rooms weekly to ensure the system is operating correctly for compliance ongoing
Standard #:	22VAC40-73-960-C
Description:	Based on observation and staff interview, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police and Poison Control Center was posted by phones identified on the facility Emergency exit plan. Evidence: 1. On 9-10-19during a tour of the facility, the facility's emergency evacuation drawing in ALFI- the telephone located at the nursing station on the first floor noted only the number for poison center. The posting on D-Wing first floor also noted information for posting in the kitchen, however, there was no posting in the kitchen. 2. Information discussed during exit with administrator and team on day 2.
Plan of Correction:	1. The emergency phone numbers to contact Fire, Police, Ambulance and Poison Control were posted next to the phones-completed on 9/11/2019. 2. An audits of phones will be completed by the Executive Director/ designee to verify numbers are in place per the emergency preparedness plan. 3. The appropriate associates have been re-educated on the requirement to check for postings at the start of each shift. 4. To assist with ongoing compliance the Assisted Living Director/designee will complete weekly checks for one month.