VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Charter Senior Living of Williamsburg
440 McLaws Circle
Williamsburg, VA 23185
(757) 221-0018

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: March 10, 2020 and March 11, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

Representatives with the Division of Licencing conducted an unannounced, non-mandated, monitoring inspection on 03/10/2020 from approximately 2:22pm to 5:52pm and on 03/11/2020 from approximately 7:06am to 8:10am. At the point of entrance the facility Administrator was available and present on 03/10/2020 and facility staff in charge was available and assisted on 03/11/2020. The Licencing Inspectors observed the facility physical plant, tested the secure unit exit door alarm, reviewed resident records and interviewed staff. Areas of non-compliance are found within this violation notice. Please complete the "plan or correction" and "date to be corrected" for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring preventative. Please contact the facility Licensing Inspector Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-1040-A
Description:	Based on staff interviews and observation the facility failed to ensure doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence #1: While interviewing staff #4, staff #4 was in the dining room assisting residents during the dinner meal time. The private duty aide for resident #2 walked into the dining room and notified staff #4 that the exit door alarm located on the 3rd hall was engaged. Staff #4 reported to the Licensing Inspector during the interview, that the alarm could not be heard in the dinning room during the meal time. Staff #4 arrived to the exit door and found resident #1 who was in a wheelchair, down the first flight of stairs. Evidence #2: On 03/10/2020 while conducting a interview with staff #5, staff recalled, that the staff member was headed home and standing at the elevator located by the facility secure care unit heard the alarm engaged. Staff #5 entered the secured unit and arrived to an exit door, where another staff was located.The staff member arrived to find the door that the staff member arrived at was not the exit door of the alarm that was engaged. When staff #5 arrived, resident #1 was already outside the facility secure unit, down the first flight of stairs. Evidence #3: On 03/10/2020 while engaging the facility secure unit exit door alarm outside of meal time with staff #1, the exit door alarm was not heard by the Licensing Inspector. Based on statements provided by staff #1, the exit door alarm could be heard faintly. Evidence #4: On 03/10/2020 with staff #3 on the facility secure unit, staff #3, " informed that the door alarm could not be heard" while standing in the secure unit dining room outside of meal time. Staff #1 asked staff #3 if it could be heard faintly and staff #3 agreed. Evidence #5: On 03/11/2020 two Licensing Staff and the facility staff person in charge engaged the facility secure unit alarm outside of meal time. The two Licensing Staff were not able to hear the exit door alarm located on the 3rd hall of the secure unit.
Plan of Correction:	Additional alarm annunciator by the BTR Dining Room was added on 3.23.2020 so that staff are able to hear when and/if the stairwell #1 door alarms. Direct care staff has been instructed to report any audible issues with any door alarms. Maintenance Director will test door alarms on the Bridge to Rediscovery 3 times a week for 4 weeks then weekly for 2 months to ensure that the alarms are audible throughout the unit, to begin 8.1.2020 and end 10.31.2020. Date: 08/01/2020 Person(s) responsible for implementation of each step and/or monitoring preventative measures: The ED is responsible to ensure implementation of each step and for monitoring preventative measures
Standard #:	22VAC40-73-450-A
Description:	Based on record review and staff interviews the facility failed to ensure on or within seven days prior to the day of admission a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence #1: On 03/10/2020 while reviewing resident record #1, the record indicated the resident was at moderate or high risk for falls based on the facility "Resident Services- Level of Care Program Review" completed on 1/21/2020. Evidence #2: The facility "Morse Fall Risk" evaluation completed on 02/22/2020 identified resident #1 with a score of 75 and indicated the resident was at high risk for falls. Evidence #3: The facility " Resident- Personal/Social Data" completed 1/26/2020 located under "Current Behavior and Social Functioning including Strengths and Problems" identifies resident #1 is a fall risk. Evidence #4: Resident #1's individualized service plan signed by the nurse completing the individualized service plan dated 2/21/2020 did not identify the need for fall interventions.
Plan of Correction:	Resident #1 no longer resides in the community. The DRC/ designee will audit current residents introductory ISP or comprehensive ISP reviewed to ensure that the ISP accurately reflects the resident?s current fall risk rating and has appropriate interventions. Date: 08/01/2020 Current staff certified to complete the Individualized Service Plan will be re-educated to include a residents fall risk rating and interventions on all introductory ISP and comprehensive ISPs by the Regional Director of Healthcare who is an appropriately certified ISP trainer. Date: 08/01/2020 ED/designee will review introductory ISPs and updated comprehensive ISPs to ensure fall risk is identified with appropriate interventions weekly for 4 weeks then every other week for 2 months to begin on 8/1/2020 and end on 10/31/2020. Date: 08/01/2020
Standard #:	22VAC40-73-460-D
Description:	Based on staff interviews, the facility failed to provide supervision of resident schedules, care, activities, including attention to specialized needs, such as prevention of falls. Evidence #1: While interviewing secure unit direct care staff #4, #6 and #7 on 3/10/2020, the Licensing Inspector asked if staff #4, #6 and #7 had reviewed resident #1's individualized service plan. Staff #4, #6 and #7 responded "no". The Licensing Inspector asked staff #6 how would staff know that resident #1 is a fall risk and required fall intervention, staff #6 stated, "by word of mouth". Licensing Inspector asked staff #4 and #7 if the staff knew where the facility individualized service plans were located and the response was, "no" .Licensing Inspector asked staff #4 and #7, if they had reviewed any facility individualized service plan and the response was, "no". Evidence #2: Nurses notes reviewed on 03/10/2020 and dated 03/04/2020 for resident #1, documentation read, " found in stairway bottom of 1st flight. S. T notes to (L) leg and multiple (R) arm. Lump on back of head." Documentation read on the facility nurses notes dated 03/05/2020, "client arrived back to MSW via medical transport. Alert, left scalp Hematoma." "After visit summary dated 3/4/2020 referenced diagnosis of multiple skin tears, Hematoma of scalp." Evidence #3: On 03/10/2020 while reviewing nurse notes that references a subsequent/additional fall that occurred at 7:45am the morning of 03/10/2020 reads, "found on floor at bedside left leg bent at knee limited ROM due to pain hospice notified...aid sitting with resident hospice nurse evaluated determined to send to ER ambulance called.' The Licensing Inspector received a self report update on 03/10/2020 at 6:34pm which reads, " ...Dx: left hip proximal fx; will have surgery on Wed., 3/11 at 11am" Evidence #4: While interviewing staff #1 and #2 on 03/10/2020 regarding resident #1's fall that occurred on 03/04/2020. Licensing Inspector inquired as to why resident #1's individualized service plan did not identify resident #1 as a fall risk nor contain fall prevention's. Staff #2 returned on two separate occasions with two different single page individualized service plan one dated 02/20/2020 and the other dated 03/04/2020. The Licensing Inspector provided evidence to staff #1 and #2 of the residents individualized service plan, which contained a 3 hole punch, stapled and located within the residents 3 ring binder. The Licensing Inspector exited the room with staff #1 to conduct additional staff interviews and returned to find the document provided by staff #2 (which did not contain a 3 hole punch prior to the Licensing Inspector exiting the room) had been 3 hole punched in the Licensing Inspector's absence. The Licensing Inspector asked staff #1 and #2 regarding the item that was punched in the Licensing Inspectors absence. Staff # 2 responded that staff #2 had added a 3 hole punch to the document.
Plan of Correction:	Staff members # 4, 6 and 7 will be re-educated to the residents Individualized Service Plan and how to identify resident needs including how to identify that a resident is a fall risk. Date: 08/01/2020 DRC/Designee will add a "Fall Risk & Fall Prevention section to the Introductory Review-Preliminary Care Plans and ensure that all new residents have the Fall Risk & Fall Prevention section completed, if applicable. Date: 08/01/2020 Current LPNs, RMA, and RSAs will be re-trained on the existing resident Introductory Service Plan with documentation of education completed. Date: 08/01/2020 Staff members will review new resident Introductory Service Plan within 72-hours of admission. Date: 08/01/2020 ED/designee will audit new admission Introductory Service Plans weekly for 4 weeks than every other week for 2 months, to begin on 8/1/2020 and end on 10/31/2020. Date: 08/01/2020 Person(s) responsible for implementation of each step and/or monitoring preventative measures: The ED is responsible to ensure implementation of each step and for monitoring preventative measures Introductory Review-Preliminary Care Plan and ensure that if applicable for new residents that the Fall Risk & Fall Prevention section is completed.