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. 15, 2021 , Sept. 16, 2021 , Sept. 30, 2021 and Oct. 7, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 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:

A renewal inspection was initiated on 9-15-2021 and concluded on 10-7-2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 105. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed five resident records, five staff records, activities calendar, staff schedules, fire and health inspections, healthcare oversight, nutrition and pharmacy reports and fire and emergency preparedness submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10-7-2021. An exit interview was conducted with the Administrator, Assistant Executive Director and other staff members on 9-30-2021 and 10-7-2021. where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-70-A
Description:	Based on record review and staff interview, the facility failed to ensure it report to the licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety or welfare of any resident. Evidence: 1. Resident #3?s Progress Notes, dated 8-27-21 at 14:30 documented resident readmitted from a local hospital with new medication orders, a catheter and 2 liter nasal cannula. An incident report was not sent to the licensing office. 2. Resident #4?s Progress Notes, dated 6-1-21 out to emergency room and 6-8-21 documented resident?s return from hospital. Resident out to hospital on 6-22-21 and returned from hospital on 6-28-21 with ?contact precautions in place due to C-Diff?. 3. On 9-30-21 and 10-7-21 during the exit, incident reporting was addressed with staff #1 and #2.
Plan of Correction:	1. Resident # 3 and #4 were sent out for change in condition, no incident had occurred. 2. Incident reports will be audited to ensure a report of a major event that had negatively affected or threatened the life, health, safety or welfare of a resident was reported to the licensing office per state regulation. Associates will be re-educated on state requirement of reporting a major incident that negatively affects or threatens the life, health, safety, or welfare of a resident. 3. Health and Wellness Director and Executive Director or designee will continue to monitor and report major events that negatively affects or threatens the life, health, safety or welfare of a resident. 4. Responsible party: Health and Wellness Director and Executive Director 5. Completion: December 31, 2021 and on-going
Standard #:	22VAC40-73-210-B
Description:	Based on record review and staff interview, the facility failed to ensure one of five sampled staff record documented at least 18 hours of annual training. Evidence: 1. Staff #8?s training record documented 4.25 hours of the required 18 hours of annual training. Staff record documented staff?s date of hire 6-17-19. 2. On 9-30-21 during the exit, staff #1 and #2 acknowledged staff?s record did not include 18 hours of training.
Plan of Correction:	1. Staff #8 will complete the additional 13.5 hours of annual training by December 31, 2021. 2. HR Manager will audit Employee Files to ensure Direct Care Staff have 18 hours of annual training by December 31, 2021. 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 Training Files monthly for annual compliance of training requirements. 5. Completion date: December 31, 2021 and on-going
Standard #:	22VAC40-73-210-F
Description:	Based on record review and staff interview, the facility failed to ensure two of five sampled staff record documented at least two hours of infection control and prevention and at least four hours of topics related to resident?s mental impairments. Evidence: 1. Staff #6?s training record documented 2 hours of the required 4 hours of topics related to resident?s mental impairments; staff?s date of hire, 3-11-20. Staff #8?s record did not include documentation of topics related to resident?s mental impairments; staff?s date of hire, 6-17-19. 2. Staff #7?s training record documented 1.50 hours of infection control and prevention training; staff?s date of hire 5-8-18. 3. On 9-30-21 during the exit, staff #1 and #2 acknowledged staff?s record did not include required hours of training.
Plan of Correction:	1. Staff #6 will complete the additional 2 hours of mental impairment training by December 31, 2021. Staff #8 will complete 4 hours of mental impairment training by December 31, 2021. Staff #7 will complete the additional .5 hours of infection control training by December 31, 2021. 2. HR Manager or designee will audit Employee Files for completion of required hours of Infection Control Training and mental impairment training. Employees will be supervised to complete the required training per state regulation and Brookdale policy. 3. Responsible Party: HR Manager 4. HR Manager and/or designee will audit 20% of Associate Files monthly for annual Infection Control training and mental impairment training per state regulation and Brookdale policy. 5. Completion date: December 31, 2021 and on-going
Standard #:	22VAC40-73-250-D
Description:	Based on record review and staff interview, the facility failed to ensure one of five sampled staff records included documentation of a subsequent tuberculosis (TB) evaluation and report. Evidence: 1. Staff #8?s training record did not include documentation of an annual TB evaluation and report; staff?s date of hire, 6-17-19. 2. On 9-30-21 during the exit, staff #1 and #2 acknowledged staff?s record did not include an annual TB report.
Plan of Correction:	1. A Tuberculosis screening was completed on Staff #8 on October 8, 2021. 2. The Executive Director and/or designee will re-educate the HR Manager on annual tuberculosis screenings per state regulations. The HR Manager or designee will audit current staff records for annual tuberculosis screening documentation per state regulations. 3. Responsible Party: HR Manager 4. The HR Manager or designee will audit 25% of staff records monthly for compliance of annual tuberculosis screening. 5. Completion date: December 31, 2021 and on-going
Standard #:	22VAC40-73-260-A
Description:	Based on record review and staff interview, the facility failed to ensure one of five sampled staff records included documentation of current certification in first aid. Evidence: 1. Staff #8?s training record did not include documentation on current certification in first aid. 2. On 9-30-21, during the exit, staff #1 stated the cards were not printed. The facility was given the opportunity to forward documents to the inspector. Staff #1 forwarded inspection documents on 10-1-21 and 10-4-21. Documentation of staff #8?s certification in first aid was not included in documents received following the exit on 9-30-21.
Plan of Correction:	1. Staff #8 will complete a first aid training course by December 31, 2021. 2. The HR Manager or designee will audit clinical employee files for proof of first aid training. Employees in need of first aid training will complete the training by December 31, 2021. 3. Responsible Party: HR Manager 4. HR Manager and/or designee will audit 20% of Associate Training Files monthly for compliance of first aid training requirements per state regulations. 5. Completion date: December 31, 2021 and on-going
Standard #:	22VAC40-73-290-A
Description:	Based on document reviewed, the facility failed to ensure the written work schedule that is maintained for two years indicated whomever is in charge at any given time. Evidence: 1. The written September 2021 staff schedule for building AL-1 did not indicate whomever is in charge at any given time. 2. On 9-30-21 during the exit, staff #1 stated the staff person in charge is posted in each building.
Plan of Correction:	1. The written work schedule for AL1 has been updated to reflect whomever is in charge at any given time. 2. The Executive Director or designee will re-educate AL Director on state regulation and Brookdale policy on staff schedules. 3. Responsible party: Executive Director 4. The Executive Director or designee will audit associate work schedule monthly to ensure names, job classifications and person in charge listed. 5. Completion date: December 31, 2021 and ongoing.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care need for four of five sampled resident?s record Evidence: 1. Resident #2?s August and September 2021 medication administration record (mar) documented resident prescribed Zyprexa, start date 6-19-21. Resident?s record did not include a signed treatment plan for psychotropic medication. 2. Resident #3?s signed physician?s order dated 8-3-21 and August 2021 mar documented Mirtazapine, with a start date of 3-17-20. Resident?s record did not include a signed treatment plan for psychotropic medication. 3. Resident #4?s August 2021 mar documented Zoloft with a start date of 5-21-21. Resident?s record did not include a signed treatment plan for psychotropic medication. 4. Resident #4?s August 2021 mar documented Cymbalta (start date of 8-3-21); Trazadone (start date 8-2-21) and Buspirone (start date 8-2-21). Resident?s record did not include a psychotropic treatment plan. 5. On 9-30-21, during the exit meeting, the facility was given the opportunity to forward documents to the inspector. Staff #1 forwarded inspection documents on 10-1-21 and 10-4-21. Documentation of the aforementioned residents? psychotropic treatment plans were not included in documents received following the exit on 9-30-21.
Plan of Correction:	1. A Psychotropic Treatment Plan for Zyprexa will be received by physician and documented in chart for Resident #2 by November 30, 2021. A Psychotropic Treatment Plan for Mirtazapine will be received by physician and documented in chart for Resident #3 by November 30, 2021. A Psychotropic Treatment Plan for Zoloft, Cymbalta, Trazodone and Buspirone will be received by physician and documented in chart for Resident #4 by November 30, 2021. 2. Resident records will be audited for requirement of psychotropic treatment plans and obtained from the physician as necessary. The District Clinical Director or designee will educate the Health and Wellness Director on appropriate diagnosis and treatment plans of psychotropic medications per state regulation 22VAC40-73-(5)-310-H. 3. Responsible Party: Health and Wellness Director 4. The Health and Wellness Director or designee will audit 25% of resident charts for psychotropic treatment plan documentation for each psychotropic medication. The audit results will be brought to the Quality Assurance meeting. 5. Completion date: December 31, 2021 and on-going.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the resident?s individualized service plan (ISP) for four of five sampled records included all assessed needs. Evidence: 1. Resident #1?s record documented physical therapy evaluation and services on 9-9-21. This service was not documented on the resident?s ISP, last signed and dated 5-14-21. 2. Resident #2?s record documented physician?s order dated 9-7-21 and Progress Notes dated 9-7-21 documented, home health nursing services for sacral ulcers, home health nursing notes document services began 9-8-21. Resident also began physical therapy services on 9-8-21. These services were not documented on the resident?s ISP dated 3-22-21. 3. Resident #3?s ?Client Coordination Notes Report? documented physical therapy services evaluated and began on 9-8-21 and Occupational services evaluated and began on 9-9-21. These services were not documented on resident?s ISP dated 8-27-21. 4. Resident #5?s Progress Notes and Order Summary Report documented the following allergies: (a) Reglan, (b) Wellbutrin and (c) Zyprexa. These allergies were not documented on the ISP dated 7-30-21. 5. On 9-30-21, information not documented on the aforementioned resident?s ISP were reviewed with staff #1 and #2.
Plan of Correction:	The following is the Plan of Correction for Brookdale Chambrel Williamsburg regarding the Statement of Deficiencies dated September 15, 16 and 30, 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. 1. The ISP for Resident #1, #2, and # 3 will be updated to reflect current assessed needs. The ISP for Resident #5 was updated to reflect allergies. 2. Resident ISPs will be audited for documentation of assessed needs and corrected as necessary by the Health and Wellness Director or designee. The clinical nursing staff will be re-educated on ISP documentation. 3. The Health and Wellness Director will audit 10% of resident records monthly to acknowledge the residents assessed needs have been included/updated on ISP. 4. Responsible party: Health and Wellness Director. 5. Correction date: December 31, 2021 and ongoing
Standard #:	22VAC40-73-450-D
Description:	Based on record review, the facility failed to ensure when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan (ISP) for one of five sampled records. Evidence: 1. Resident #4?s individualized service plan (ISP) document hospice services with an identified need date of 8-3-21. However, the services provided are not documented on the service plan. 2. On 9-30-21 during the exit, staff #1 and #2 acknowledged the ISP did not include the specific hospice services being provided.
Plan of Correction:	1. The ISP for Resident #4 will be updated to reflect current assessed needs including hospice services. 2. Resident ISPs will be audited for need to include hospice care services. Hospice care services will be included on the ISP for resident under hospice care. The clinical nursing staff will be re-educated on ISP documentation when hospice services are rendered. 3. The Health and Wellness Director or designee will audit 10% of resident records to acknowledge the residents assessed needs have been included/updated on ISP. 4. Responsible party: Health and Wellness Director. 5. Correction date: December 31, 2021 and ongoing.
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 for one of five sampled records. Evidence: 1. Resident #1?s admitting physical examination signed and dated 5-3-21 documented occupational therapy evaluation and treat. The resident?s individualized service plan did not document resident?s receiving services. The resident?s progress notes did not document resident receiving services. 2. On 9-30-21, physician?s order for occupational therapy evaluation and treatment not being completed was addressed with staff #1 and #2.
Plan of Correction:	1. Resident #1 Occupational Evaluation and Treatment was completed on 05/27/2021. Resident moved in 5/14/2021. 2. Resident records will be audited for ordered healthcare service needs. The audit will include the ISP and documentation in notes. The clinical nursing staff will be re-educated on ISP and clinical documentation. 3. The Health and Wellness Director or designee will audit 10% of resident records monthly to acknowledge the residents assessed needs have been included/updated on ISP and documented in notes. 4. Responsible party: Health and Wellness Director. 5. Correction Date: December 31, 2021 and ongoing
Standard #:	22VAC40-73-650-A
Description:	Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedures, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications for five of five sampled records. Evidence: 1. Resident #1?s August and September 2021 medication administration record (mar)documented the following medications were administered and started, changed, or discontinued without signed physician or prescriber?s order: (a) Mobic 7.5 mg discontinued 8-10-21, (b) Norco 7.5-325 mg, twice a day discontinued 9-10-21, the resident?s progress note dated 9-10-21 at 22:14 also documented discontinued medication, (c) Norco 7.5-325 mg prn every 24 hours, started 7-15-21, (d) Norco 7.5-325mg every 6 hours, started 8-17-21 and discontinued 8-24-21, (e) PreserVision AREDs started 7-15-21; (f) Zofran 4mg prn, started 5-27-21. 2. Resident #2?s documentation of sixteen medications on August 2021 MAR and thirteen medications documented on September 2021 MAR, physician?s orders not received per inspection request for documents on 9-16-21 and 9-30-21. 3. Resident #3?s August 2021 did not include signed physician?s orders for the following: (a) Vitamin D, (b) Cozaar, (c) Melatonin, (d) Dexamethasone, (e) Thera Tab multivitamin, and (f) Cephalexin Suspension. 4. Resident #4?s August 2021 MAR did not include signed physician?s orders for the following: (a) Fidaxomicin start date 8-19-21 and discontinued 8-23-21, (b) Flagyl 500mg start date 8-23-21 and (c) Potassium Chloride discontinued 8-3-21. 5. Resident #5?s August 2021 MAR did not include signed physician?s orders for the following: (a) Buspirone (b) Spironolactone and (c) Restasis 0.05% discontinued 8-3-21. 6. On 9-30-21 and 10-7-21 during exit meeting, physician?s or prescriber?s orders not being available were addressed with staff #1 and #2.
Plan of Correction:	1. For Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 signed physician/prescribers orders were obtained for the medications that were administered and started, changed, or discontinued. 2. Resident records will be audited for valid signed physician/prescribers orders for medications, dietary supplements, diet, and medical procedures/treatments that have been started, changed, or discontinued. Healthcare provider orders awaiting signatures will be given to the healthcare provider for their signature. The clinical nursing staff will be re-educated on valid and signed physician and/or prescriber orders. 3. Responsible party: 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. 5. Completion date: December 31, 2021 and ongoing.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing for one of five sampled records. Evidence: 1. Resident #1?s physician?s order dated 8-10-21, documented ?STOP Diclofenac?. Resident?s August medication administration record (mar) documented medication was administered seven times following the discontinuation order. 2. On 9-30-21 during the exit, staff #1 and #2 acknowledged documentation of the medication?s administration following the discontinued order.
Plan of Correction:	1. Resident #1 physician order for diclofenac has been clarified and, physician and responsible party were informed of the administration of medication for an additional 7 doses. 2. Resident records were audited for appropriate administration of medications in accordance with the physician/prescribers instructions. The clinical staff will be re-educated on medication administration in accordance with the physician?s/prescriber?s instructions and consistent with the standards of practice of the Virginia Board of Nursing. 3. The Health and Wellness Director or designee will audit 10% of resident records/MARs monthly for accurate administration of medications. 4. Responsible party: Health and Wellness Director. 5. Completion date: December 31, 2021 and ongoing.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents including over-the-counter medications and dietary supplements include all regulatory requirements for three of five sampled records. Evidence: 1. Resident #1?s August 2021 and September medication administration record (MAR) was blank/did not include the initials of the direct care staff administering the following medications: (a) Levothyroxine and (b) Prilosec on 8-3-21, 8-14-21-and 8-15-21 and 9-8-21 and (c) Norco 5-325mg-(prescribed three times a day)-on 9-13, 9-14, and 9-15-21. 2. Resident #3?s August 2021 MAR was blank/did not include the initials of the direct care staff administering the following: (a) Aspirin, CoQ10, Cozaar, Omeprazole, Thera multivitamin and Namenda on 8-5-21 and (b) Aricept, Remeron, Pravastatin and Namenda on 8-14-21. 3. Resident #4?s August 2021 MAR was blank/did not include the initials of the direct care staff administering the following: (a) Lantus Solostar on 8-6-21 and (b) Humalog on 8-15-21. 4. On 9-30-21 during exit, MARS were addressed with staff #1 and #2.
Plan of Correction:	1. Resident #1 PCP and responsible party will be informed of missed medication administration on 8/3/21, 8/14/21, 8/15/21 9/8/21, 9/13/21, 9/14/21, and 9/15/21. Resident #3 PCP and responsible party of missed medication administration on 8/5/21 and 8/14/21. Resident #4 PCP and responsible party were informed of missed medication administration on 8/6/21 and 8/15/21. 2. Resident MARs will be audited for missed documentation of medication administration. The clinical staff will be re-educated on medication administration and documentation. 3. The Health and Wellness Director or designee will audit 10% of resident MAR (Medication administration record) monthly for documentation compliance. 4. Responsible party: Health and Wellness Director. 5. Completion date: December 31, 2021 and ongoing
Standard #:	22VAC40-73-700-1
Description:	Based on record review and staff interview, the facility failed to ensure when oxygen therapy is provided, the facility shall have a valid physician?s or other prescriber?s order that included all of the regulation requirements for one of five sampled records. Evidence: 1. Resident 3?s individualized service plan (ISP) dated 8-27-21 and progress notes dated 8-27-21 at 14:30 p.m. documented resident?s use of oxygen via nasal cannula. Resident?s record did not include a physician?s order for oxygen therapy. 2. On 9-30-21 during exit, staff #1 and #2 inspector addressed resident?s record not having physician?s order for oxygen. Staff #1 sent additional documents on 10-1-21 but documents received did not included physician?s orders for resident #3?s oxygen therapy.
Plan of Correction:	1. Resident #3 discharge summary and discharge instructions dated 8/27/21 included documentation for Oxygen therapy to include oxygen source, delivery device and flow rate 2.For residents receiving oxygen, records will be audited for valid physician/prescriber orders for oxygen and orders will be obtained if necessary. The clinical nursing staff will be re-educated on valid physician and/or prescriber orders for oxygen therapy. 3. Responsible party: Health and Wellness Director. 4. The Health and Wellness Director or designee will audit 10% of resident records monthly for valid physician/prescriber orders when oxygen therapy is administered. 5. Correction date: December 31, 2021 and ongoing.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviews, the facility failed to ensure the interior of the building was maintained in good repair and kept cleaned and free of rubbish. Evidence: 1.On 10-7-21, during a tour of building #2?s (safe, secure, unit), the following was observed in room #C-15: (a) the carpet contained brown and grey particles; (b) a large stained area was located near the outlets on the left wall; (c) the base board is separating from the wall and three scrapes/ scratch marks approximately 6 inches long on the lower left wall and (d) the window contained dark colored debris. 2. Staff #2 and #10 acknowledged, room #C-15 was not maintained in good repair and kept cleaned.
Plan of Correction:	1. The Maintenance Director and/or designee will have apartment #C-15 carpet replaced, walls repaired and painted, windows cleaned, apartment cleaned and restored back to good condition by December 31, 2021. 2. The Maintenance Director or designee will inspect resident units and interior of building for maintenance and rubbish. Areas found to be needing of repair or cleaning will be corrected. The Executive Director or designee will provide education for Maintenance Director and Maintenance Technician?s on maintenance of interior and exterior to be kept in good repair, clean and free of rubbish per state regulations and Brookdale policy. 3. Responsible Party: Maintenance Director 4. The Maintenance Director and/or designee will visually inspect 25% of resident apartments monthly to ensure apartments are kept in good repair, kept clean and free of rubbish. 5. Completion date: December 21, 2021 and ongoing.
Standard #:	22VAC40-73-930-A
Description:	Based on observation and staff interviews, the facility failed to ensure staff was able to receive the alert from the facility?s signaling device. Evidence: 1. On 10-7-21 during a tour of the facility, the call bell was pulled in the bathroom in room #306 located in building #3, 3rd floor (on the safe, secure) unit at 11:39 a.m. At 11:45 a.m. there was no response, the inspector inquired of staff #10 regarding the call bell system. Staff #11 was also asked why there was no response. Staff #12 was the individual with the pager, but stated not hearing the signal. Further conversation with staff members determined, staff #12 possessed the only pager on the unit. The other care staff did not have pagers and therefore did not respond to the signal alert for room #306. 2. Staff #2 acknowledged there was only one pager available on the unit.
Plan of Correction:	1. A 2nd pager was programmed and given to Staff #11 on the day of inspection, October 7, 2021, so all direct care staff in unit would receive alerts when a resident needs assistance. 2. The Executive Director or designee will audit individual units for adequate pagers for staff; pagers will be purchased if necessary. Direct Care Staff will be re-educated on provisions for signaling and call systems. 3. Responsible Party: Executive Director 4. The Executive Director or designee will complete monthly audits on pagers to verify pagers are present and in good working condition. 5. Completion date: December 31, 2021 and on-going
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviews, the facility failed to ensure the first aid kit in each building was completed. Items with expiration dates must not have dates that have already passed. Evidence: 1. An examination of the first aid kit in Building #3?s (safe, secure unit) with staff #11, determined the following items were missing: (a) Band-Aids in assorted sizes; (b) blankets, either disposable or other; (c) flashlights and extra batteries; (d) cold pack; (e) thermometer; (f) triangular bandages. 2. An examination of the first aid kit on the first floor of Building #3 with staff #13, determined the hand sanitizer had an expiration date of 9-24-20. 3. On 10-7-21, during the on-site exit, staff #2 acknowledged the first aid kits were not completed and the hand sanitizer had expired.
Plan of Correction:	1. The Band-Aids in assorted sizes, blanket, flashlight with extra batteries, cold pack, thermometer and triangular bandage in Building #3 3rd Floor (secure unit) and the hand sanitizer in Building #3 first floor were replaced on October 26, 2021. 2. An Audit of First Aid Kits will be completed for item not expired and kits are complete. First Aid Kit items will be replaced as necessary. The District Director of Clinical Services or designee will re-train the Health and Wellness Director and the Health and Wellness Coordinators on First Aid Kit contents and maintenance. 3. Responsible Party: Health and Wellness Director 4. The Health and Wellness Director and/or designee will complete monthly audits to verify all First Aid Kits are appropriately stocked and expiration dates are noted. 5. Completion date: December 31, 2021 and on-going.