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. 2, 2020 , Sept. 3, 2020 , Sept. 4, 2020 , Sept. 8, 2020 , Sept. 18, 2020 and Oct. 8, 2020

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 9-2-20, 9-3-20,9-8-20 and concluded on 9-17-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 101. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records, 5 staff records, physician's orders, staff schedule, healthcare oversight, health department inspection, fire and emergency drills, and new hire since last renewal inspection date, sworn statement/affirmation, and criminal history record report. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1140-E
Description:	Based on record review and staff interview, the facility failed to ensure staff other than the administrator and direct care staff complete 2 hours of training in cognitive impairment within the first month of employment. Evidence: 1. During the remote renewal inspection, a review of staff #7?s record documented the following cognitive training hours and dates: (a) 7-15-19 (18 minutes and (b) 7-15-19 (37 minutes). Staff #7?s date of hire was noted as 7-12-20. Staff #7?s record did not include documentation of the regulatory requirement of 2 hours of cognitive training within the first month of employment. 2. During the exit interview on 9-17-20, staff #1 and #2 acknowledged staff did not complete required cognitive training hours within first month of employment.
Plan of Correction:	1. Staff #7 will complete the additional 65 minutes of Cognitive training by December 31, 2020. 2. HR Manager will audit Employee Files for Cognitive Training by December 31, 2020. Employees will complete the training per state requirement and Brookdale policy. 3. Responsible Party: HR Manager 4. HR Manager and/or designee will audit 20% of Associate Files monthly for Compliance in Cognitive Training which is required within the first month of their start of employment. 5. Completion date: December 31, 2020 and on-going.
Standard #:	22VAC40-73-210-F
Description:	Based on record review and staff interview, the facility failed to ensure at least two of the required annual training hours focused on infection control and prevention for two of five staff sampled staff records reviewed. Evidence: 1. During the remote renewal inspection a review of staff #3?s record did not include a full year of training hours based on staff?s date of hire, 1-18-19. Documents with training dates received were dated 10-2-19 thru 12-4-19. On 9-9-20 during review with staff #1 and #2, a request was made for additional training documentation. A review of the requested document received on 9-10-20 included additional training dates and hours of training. A review of the training documents provided was made and staff #3?s record noted the following annual infection control and prevention training hours: (a) 1-9-19 (1.11 minutes) and (b) 11-1-19 (30 minutes). The regulatory requirement for annual hours of infection control for staff is 2 hours. 2. Further review of the sample records revealed, staff #4?s training record noted the following annual infection control and prevention training hours: (a) 11-1-19 (30 minutes) and (b) 12-12-18 ( 1.11 minutes). Staff # 4?s date of hire noted as 12-12-18; review of training hours presented did not document the required 2 hours of annual infection control. 3. Staff #1 and #2 acknowledged, during the exit interview, on 9-17-20, staff?s records did not contain required 2 hours of annual infection control and prevention training.
Plan of Correction:	1. Staff #3 will complete the additional 21 minutes of Infection Control Training by December 31, 2020. Staff #4 will complete the additional 21 minutes of Infection Control Training by December 31, 2020. 2. HR Manager will audit Employee Files for Infection Control Training by December 31, 2020. Employees will complete the training per state requirement and Brookdale policy. 3. Responsible Party: HR Manager 4. HR Manager and/or designee will audit 20% of Associate Files monthly for Infection Control training which is required annually. 5. Completion date: December 31, 2020 and on-going
Standard #:	22VAC40-73-290-A
Description:	Based on document review and staff interview, the facility failed to ensure the written work schedule contained all required information. Evidence: 1. During the remote renewal inspection, a review of the dietary staff schedules submitted on 9-4-20 noted the followings: (a) dietary schedules for AL-1 noted only the first name of staff and no job classification was included, (b) Assisted Living-1 & Clarebridge dietary schedule for cooks dated 8-30 thru 9-5-20 noted only staff?s first name; all other dietary schedules for Assisted Living -1 & Clarebridge noted first name and no job classification; (c) Assisted Living 2 dietary schedules noted first name only and no job classification. 2. Further review of the housekeeping schedules submit on 9-4-20, the schedules for AL-1, 2nd and 3rd floor, AL-1, 1st floor and AL-2- Clairebridge noted permanent schedule, but did not include the month, date or year on the schedule. 3. A review of the maintenance schedule submitted for AL1, Al2, Crossings, Clarebridge did not include the month, date or year on the schedule. 4. During exit interview on 9-17-20, staff #1 and #2 acknowledged the non-nursing staff schedules did not include all required information.
Plan of Correction:	1. The current work schedule for the Staff in Dining Services- AL1 and Clare Bridge was updated to reflect full name and job classification. The current work schedule for AL1-1,2 and 3 floors and Clare Bridge was updated to reflect month, date and year. The current work Schedule for Maintenance for AL1, AL2 and Clare Bridge was updated to reflect month, date and year. The current work Schedule for Housekeeping for AL1, AL2 and Clare Bridge was updated to reflect month, date and year. 2. The Dining Services Director, Maintenance Director and Housekeeping Manager will review monthly staffing schedule for completion per state regulation and Brookdale Policy before posting. Executive Director will re-educate Dining Services Director, Maintenance Director and Housekeeping Manager on State Regulation and Brookdale Policy on Staff Schedules 3. Responsible Party: Executive Director. 4. The Dining Services Director, Maintenance Director and Housekeeping Manager will audit monthly the Associate work schedule to include month, date, year, job classification and full name of each associate 5. Completion date: November 30, 2020 and on-going.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of five sampled residents. Evidence: 1. During the remote renewal inspection, a review of resident #3?s uniformed assessment instrument (uaI) dated 5-21-20, bathing need assessed as mechanical help/human help/physical assistance. A review of the individualized service plan (ISP) developed 5-21-20 did not document a mechanical device. Eating/Feeding need assessed as performed by others (spoonfed). A review of the ISP did not address the eating/feeding activity of daily living (adl) need. Further review of the ISP did document need for resident to be spoonfed under the meal prep (instrumental adl). However, the approximate amount of time needed for meal to ensure need is met is not documented on the ISP (22VAC40-73-580-D). 2. A review of resident #5?s uai dated 5-30-20, wheeling assessed as no need and not performed, however, the ISP plan dated 6-11-20 and signed 8-11-20 by resident?s representative did not include this assessment. Mobility assessed as mechanical help/human help/supervision, however, the ISP noted, ??resident will be transported to by POA/van driver to outside appointments?. 3. On 9-17-20 during exit interview, staff #1 and #2 acknowledged all assessed needs for residents were not included on resident #3 and #5?s ISPs.
Plan of Correction:	1. The ISP for Resident #3 was updated on 10/15/2020 to address the ADL needs reflected on the UAI. ISP for Resident #5 was updated on 10/15/2020 to reflect the assessed needs of the resident per the UAI. 2. The Health and Wellness Director has audited the UAI?s and ISP?s of Resident records to acknowledge that the residents assessed needs from the UAI are documented on the ISP. ISP?s have been updated as of October 20, 2020. The clinical nursing staff have been re-educated on UAI and ISP documentation. 3. Responsible Party: The Health and Wellness Director 4. The Health and Wellness Director and/or designee, will audit 10% of resident UAI?s and ISP?s monthly to acknowledge assessed resident needs from the UAI?s are documented onto the ISP?s. This report will be brought to the Quality Assurance meeting. 5. Completion date: November 30, 2020 and on-going
Standard #:	22VAC40-73-650-A
Description:	Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber for one of five records. Evidence: 1. During the remote renewal inspection, a review of resident #3?s unsigned physician?s orders was conducted. A review of resident #3?s August 2020 medication administration record (mar) submitted 9-4-20 was also reviewed and noted medications administered by staff without a physician?s order; a) Pyridium, start date noted on mar (8-20-20); (b) Ativan (as needed, start date 8-29-20; and (c) Fosfomycin with a start date 8-20-20 noted on the August 2020 mar. 2. A request for signed physician?s orders for medications noted on the August 2020 mar was requested from staff #1 and staff #2 on 9-9-20 and received on 9-10-20. However, a review of the signed physician?s orders received on 9-10-20 did not include orders for the medications in question. The physician order received noted the following: printed on 7-11-20, and an unclear date 7/2?/??) received on 9-10-20 did not include orders for the medications in question. 3. On 9-17-20 during exit interview, staff #1 and #2 acknowledged resident #3?s August 2020 mar documentation of medications without a physician?s order.
Plan of Correction:	1. The signed physician orders for resident #3, Pyridium, Ativan and Fosfomycin were placed in the resident record on 10-15-2020. The MAR for Resident #3 was updated to reflect current active orders on 10-15-2020. 2. The Health and Wellness Director will audit resident healthcare provider orders for appropriate signatures. Healthcare provider orders awaiting signatures will be given to the healthcare provider for their signature. 3. Responsible party: The Health and Wellness Director 4. The Health and Wellness Director or designee will audit 10% of resident physician orders monthly for completeness and healthcare provider signatures. This report will be brought to the Quality Assurance meeting for review. 5. Completion date: November 30, 2020 and on-going
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician or other prescriber?s order for administration of all prescription, and over-the counter medication included all required information. Evidence: 1. During the remote renewal inspection, a review of resident #1, August 2, 2020 signed physician?s order listed Refresh tears solution. Further review of the order revealed the document did not include the diagnosis, condition, or specific indications for administering the Refresh tears. A review of the August 2020 medication administration record (mar) also did not include a diagnosis for the Refresh tears. 2. A review of resident #1's admission physical examination dated 10-8-19, also noted the Refresh tears included with the list of medications and no diagnosis is noted on the signed physical examination. 3. On 9-17-10, during the exit interview, staff #1 and staff #2 acknowledged the physician?s orders and August 2020 MAR for resident #1 did not include a diagnosis for the Refresh tears.
Plan of Correction:	1. An order to discontinue refresh tears eye drops was are received from the physician for Resident #1 on 10/15/2020. 2. The Health and Wellness Director will audit resident physician orders to ensure the physician or other prescribers for administration of prescription and over the counter medications include required information such as diagnosis, condition of specific indications for administering the medication. 3. Responsible Party: The Health and Wellness Director 4. The Health and Wellness Director will audit 10% resident physician orders to ensure the physician or other prescribers for administration of prescription and over the counter medications include required information such as diagnosis, condition of specific indications for administering the medication. This report will be brought to the Quality Assurance meeting 5. Completion date: November 30, 2020 and on-going.
Standard #:	22VAC40-73-940-A
Description:	Based on documents review and staff interview, the facility failed to ensure at least an annual inspection by the appropriate fire official was completed. Evidence: 1. During the remote renewal inspection, the fire inspection documents submitted for the facility were dated, 9-26-18 Assisted Living- 3800 Treyburn; 9-26-18 Memory Care-3501 Treyburn and 11-20-18 Assisted Living 3800 Treyburn. 2. On 9-9-20, the inspector requested a copy of the most recent fire inspection. On 9-10-20, the inspector received an email indicating the fire inspections had not been conducted and the facility would contact the local fire inspector for an inspection. 3. On 9-17-20, during the exit interview, staff #1 and staff #2 acknowledged the facility?s annual inspection had not been conducted.
Plan of Correction:	1. The Fire Marshall performed the fire inspection on September 18, 2020, with no findings noted. 2. The Maintenance Director audited maintenance files for annual inspections by the appropriate fire official. Fire Marshall will be notified for a fire inspection if necessary. 3. Responsible party: Maintenance Director 4. Maintenance Director or designee will audit quarterly 50% of inspection records for completion. 5. Completion date: November 30, 2020 and on-going