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 7, 2022 , March 8, 2022 and March 18, 2022

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

Comments:

An unannounced IPOC inspection was conducted on 3-7-22 (ar 07:45 a.m./dep 12:55 p.m.) The census was 117. Resident and staff records were reviewed and interviews conducted. Violations were discussed with staff throughout the inspection process. The final exit meeting was conducted on 3-18-22 and request for additional documents was made and documents were received on 3-23-22. Comments: Technical assistance provided regarding need assessed as " not performed on UAIs". Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. 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. POC due within 10 days: 4-10-22

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for three of five residents. Evidence: 1. Resident #2?s February 2022 medication administration record (MAR) documented resident prescribed Venlafaxine, start date 1-22-22. The resident?s record did not include a signed and dated psychotropic treatment plan. 2. Resident #3?s February 2022 MAR documented resident prescribed Lexapro, start date 10-5-21. The resident?s record did not include a signed and dated psychotropic treatment plan. 3. Resident #5?s February 2022 MAR documented resident is prescribed Duloxetine, start date 2-1-21 and Nortriptyline, start date 1-31-22. The resident?s record did not include a signed and dated psychotropic treatment plan. 4. On 3-7-22 staff #2 acknowledged facility did not have psychotropic treatment plans for the aforementioned residents.
Plan of Correction:	1. Psychotropic Treatment Plans will be obtained for Resident #2, #3 and #5. The Executive Director, Health and Wellness Director or designee will re-audit all current resident records for those residents receiving psychotropic medications. Psychotropic treatment plans to be initiated in collaboration with the resident?s health care provider and documented on the Individual Service Plan. 2. The District Director of Clinical Services or designee will re-educate the Health and Wellness Director(s) on the appropriate diagnosis and treatment plan for psychotropic and the requirements for psychotropic treatment plans. 3. Responsible Party: Health and Wellness Director 4. To assist with ongoing compliance, the Executive Director, Health and Wellness Director or designee will review 25% of resident psychotropic treatment plans and the appropriate resident diagnosis once a month for 3 months. 5. Completion Date: April 30, 2022
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) for three of five residents included all assessed needs. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 8-6-21 documented toileting need as mechanical help/physical assistance. The resident?s individualized service plan (ISP) dated 8-24-21 physical assistance by staff. On the morning of 3-7-22, staff #9 reported to the inspector and staff #3, resident had a 3-in1- commode. This information was not documented on the ISP. Stairclimbing need assessed as mechanical help physical assistance. The ISP documented mechanical help with supervision. 2. Resident #3?s UAI dated 1-24-22 documented resident?s behavior as appropriate. The ISP dated 1-24-22 documented resident wanders passively, less than weekly. 3. Resident #4?s UAI dated 2-22-22 documented dressing need as mechanical help/ physical assistance. The ISP dated 2-23-22 documented need as physical assistance by staff. 4. On 3-7-22 staff #2 acknowledged the aforementioned residents ISP did not document the assessed needs.
Plan of Correction:	1. The ISP for Resident #1 was updated on 3/19/2022 to reflect mechanical help/physical assistance needed for toileting and mechanical help/physical assistance with stairclimbing. The ISP and UAI for Resident #3 was updated on 3/28/2022 to reflect the resident behavior pattern as appropriate. The ISP for Resident #4 was updated on 3/7/2022 to reflect mechanical help/physical assistance to match the UAI. 2. Resident ISPs will be re-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 UAI and ISP documentation. 3. Responsible Party: The Health and Wellness Director 4. To assist with on-going compliance, the Executive Director, Health and Wellness Director or designee will review 30% of resident psychotropic treatment plans twice a month for 3 months. 5. Completion date: April 30, 2022
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes for three of five residents. Evidence: 1. Resident #1?s record documented resident receive occupational therapy (OT) services on 2-14-22, 2-18-22, 2-25-22, 2-28-22, and 3-4-22. Resident?s record documented psychiatric services from an agency, dates in record were dated 9-29-21, 10-18-21 and 11-15-21. Theses service were not documented on the ISP dated 8-24-21. 2. Resident #3?s record document resident receive occupational therapy (OT) services on 2-4-22, 2-11-22, 2-17-22, 2-22-22, 2-24-22, 3-1-22 and 3-3-22. This service was not documented on the ISP dated 1-14-22. 3. Resident #5?s record documents resident receive occupation therapy (OT) services on 2-11-22, 2-16-22, 2-17-22, 2-21-22, 2-23-22, 2-28-22 and 3-2-22. The service was not documented on the ISP dated 1-31-22. 4. On 3-7-22 staff #2 acknowledged the aforementioned residents? ISP did not document the resident?s change condition and service need.
Plan of Correction:	1. The ISP for Resident #1, was updated on 3/19/2022 to reflect current Occupational Therapy and psychiatric service assessed needs. The ISP for Resident #3 ISP was updated on 3/28/2022 to reflect the Occupational Therapy assessed needs. The ISP for Resident #5 was updated on 3/18/2022 to reflect the Occupational Therapy assessed needs. OT was then discontinued on 3/22/2022 and updated on ISP. 2. Resident ISPs will be audited for documentation of assessed needs and corrected as necessary by the Health and Wellness Director of designee. The clinical nursing staff will be re-educated on ISP documentation pertaining to occupational therapy and psychiatric services. 3. Responsible Party: Health and Wellness Director 4. To assist with ongoing compliance the Health and Wellness Director or designee will audit 15% of resident records monthly for 3 months to acknowledge the residents assessed needs have been included/updated on the ISP. 5. Completion Date: April 30, 2022
Standard #:	22VAC40-73-650-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure no medication 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. Evidence: 1. Resident #4?s February 2022 medication administration record (MAR) documented resident was administered Aspirin 81 mg on 2-23-22 at 08:00 a.m. The MAR documented medication was started on 2-22-22 and discontinued on 2-23-33. Benadryl was administered on 2-23 -22 through 2-28-22 at 9:00 p.m. The MAR noted medication was started 2-23-22 discontinued on 3-1-22. 2. A request for all physician?s orders for medications listed on the residents? February 2022 MAR was requested on 3-7-22 and received on 3-8-22. 3. On 3-18-22 during the exit meeting a request for all physician?s orders for all medications on the resident?s MAR was requested. On 3-23-22 the physician?s orders received did not include orders to start and or discontinue the aforementioned medications for resident #4.
Plan of Correction:	1. For Resident #4 signed physician/prescribers orders were obtained on 3/11/2022 2. Resident records will be audited for valid signed physician/prescribers orders for medications, 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. To assist with ongoing compliance, The Health and Wellness Director or designee will audit 15% of resident physician orders twice a month for 3 months. 5. Completion Date: April 30, 2022
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #1?s record on 3-7-22 included a signed prescription dated 2-11-22 for Celecoxib but the prescription did not include the diagnosis, condition, or specific indications for administering the drug. 2. On 3-7-22 staff #2 and #3 on acknowledged the aforementioned resident?s prescription did not include the diagnosis for the drug prescribed.
Plan of Correction:	1. Resident #1 diagnosis for the Celecoxib was received by the physician on 3/7/2022. 2. Resident records will be audited for missing diagnosis of medications. Any medication orders found without a diagnosis will be given to the healthcare provider for their signature. The clinical nursing staff will be re-educated on diagnosis needed for each medication. 3. Responsible Party: Health and Wellness Director 4. To assist with ongoing compliance, the Health and Wellness Director or designee will audit 10% of Resident medication administration records (MAR) and medication orders once a week for 4 weeks and then monthly for 3 months. 5. Completion Date: April 30, 2022
Standard #:	22VAC40-73-680-K
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders for documented the exact oxygen flow rate for a resident when registered medication aides provide the service. Evidence: 1 Resident #2?s February 2022 medication administration record documented resident?s oxygen flow rate ?4-5 lpm with activity?? 2. On 3-7-22 staff #2 acknowledged the oxygen flow rate was a range and not exact flow rate.
Plan of Correction:	1. A corrected order for oxygen flow rate was received from physician on 3/31/2022. 2. Health and Wellness Director will audit resident medication administration records for compliance of oxygen orders to reflect the exact flow rate and will obtain clarification from physician if needed. The clinical staff will be re-educated on the standards for oxygen flow rate consistent with the standards of practice of the Virginia Board of Nursing. 3. Responsible Party: Health and Wellness Director 4. To assist with ongoing compliance the Health and Wellness Director or designee will audit 15% of resident records/Mars once a week for 4 weeks and then monthly for 3 months. 5. Completion Date: April 30, 2022