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: March 10, 2021 , March 11, 2021 , March 17, 2021 and April 14, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 monitoring inspection was initiated on 3-11-21 and concluded on 4-14-21. A self-reported incident was received by the department regarding allegations in the resident care and related areas of standard. The assistant executive director was contacted by telephone to conduct the investigation. The licensing inspector emailed the assistant executive director a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report allegation of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

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 a resident. Evidence: 1. On 3-12-21, resident #1?s physical examination dated 2-9-21 submitted for review, documented resident?s need for skilled nursing to be evaluated and treated. 2. Further review of resident #1?s progress notes (nurse?s notes) documented on 2-16-21, both legs of resident was wrapped by home health nurse. 3. A review of the resident?s individualized service plan (ISP) dated 2-20-21 did not document skilled nurse nursing need. 4. On 4-14-21, staff #1 provided documentation of home health providing skilled nursing services to resident #1 following resident?s 2-16-21 admission. However, this assessed need was not documented on the resident's ISP. 5. The submitted Fall Rating document for resident #1 did not include the date nor the signature of the assessor. This assessed need was not documented on the resident's ISP. 6. On 4-14-21, staff #1 acknowledged resident #1?s skilled nursing service and fall risk assessed needs were not documented on resident?s ISP.
Plan of Correction:	The following is the Plan of Correction for Brookdale Chambrel Williamsburg regarding the Statement of Deficiencies dated April 14, 2021. 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. We remain committed to the delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 22VAC40-73-(6)-450-C 1. The ISP for Resident #1 was updated on 4/26/2021 to reflect skilled nursing service and fall risk assessed needs on the ISP. 2. The Health and Wellness Director will audit the ISP?s of Resident records to acknowledge that the residents assessed needs of skilled nursing services and fall risk assessment are documented on the ISP. ISP?s will be updated accordingly. The Health and Wellness Director will be re-educated on ISP documentation by the District Director of Clinical Services by May 15, 2021. 3. Responsible Party: The Health and Wellness Director 4. The Health and Wellness Director and/or designee, will audit 10% of resident ISP?s monthly to acknowledge skilled nursing services and fall risk assessed needs are documented onto the ISP?s. This report will be brought to the Quality Assurance meeting and be reviewed at the Healthcare Oversight assessment. 5. Completion date: May 15, 2021 and on-going
Standard #:	22VAC40-73-470-A
Description:	Based on record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met. Evidence: 1. On 3-12-21, resident #1?s physical examination dated 2-9-21 review, documented resident?s need for physical therapy and occupational therapy to be evaluated and treated. 2. Further review of resident?s individualized service plan dated 2-20-21 did not document service needs. A review of resident?s progress notes (nurse?s notes) submitted did not document therapy services. 3. On 4-14-21, staff #1 acknowledged, resident #1?s physical examination included orders for therapy services. Staff also acknowledged, the facility did not provide services nor did the facility assist the resident or family in making arrangements for the recommended health care services.
Plan of Correction:	1. Resident #1 was referred for skilled nursing and had already met her therapy goals. Her ISP has been updated to reflect skilled nursing needs on 4/26/2021. The physician and POA were informed she had already met her therapy goals during a previous referral which ended prior to admission to assisted living. 2. The Health and Wellness Director will audit the physician orders of Resident records to acknowledge that the residents assessed needs of therapy services are documented on the ISP and orders are followed through with the evaluation and treatment of therapy. ISP?s will be updated accordingly. The Health and Wellness Director will be re-educated on ISP documentation and follow through on physician orders for evaluation and treatment of therapy by the District Director of Clinical Services by May 15, 2021. 3. Responsible Party: The Health and Wellness Director 4. The Health and Wellness Director and/or designee, will audit 10% of resident ISP?s and physician orders monthly to acknowledge documentation on the ISP for therapy needs and follow through on physician orders for therapy. This report will be brought to the Quality Assurance meeting and be reviewed at the Healthcare Oversight assessment. 5. Completion date: May 15, 2021 and on-going