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: Oct. 24, 2022 , Nov. 29, 2022 and Dec. 1, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint An on-site complaint inspection was conducted on 10-24-22 (Ar 10:20/dep 16:10). The facility census was 134 on 10-24-22. Staff and resident interviews were conducted. Resident records and staff training records reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10-19-22 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 134 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 7 Observations by licensing inspector: yes Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals in the assisted living with any conditions or care need prohibited by the regulation and Code of Virginia for one of four records reviewed. Evidence: 1. On 10-24-22 during a complaint inspection, resident #4?s medication administration record for October 2022 and Order Summary Report documented resident is prescribed Paxil. The record did not have documentation of a psychotropic treatment plan. 2. On 10-24-22 and 11-29-22, staff acknowledged the aforementioned resident?s record did not include a treatment plan for Paxil.
Plan of Correction:	? Unable to retroactively correct initial psychotropic treatment plans for resident number 4. ? The Psychotropic Treatment Plan for resident number 4 will be initiated by primary care provider no later than 1/01/2023. ? The Executive Director, Health and Wellness Director/Coordinator, or designee will retrain licensed nurses and registered medication aides on psychotropic treatment plans no later than 1/01/2023. ? To assist with ongoing compliance, the Health and Wellness Director or designee will audit 10 % of current residents? records for to verify documentation of psychotropic medications and psychotropic treatment plans as needed for the audited residents, no later than 01/01/2023.
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the admitting physical examination included all required information. Evidence: 1. On 10-24-22 during a complaint inspection, resident #3?s admitting physical examination dated 4-27-22 did not include resident?s height, weight and blood pressure. 2. On 10-24-22, staff acknowledged resident?s physical did not include all required information.
Plan of Correction:	?Unable to retroactively correct initial Physician Plan of Care for resident number 3 to reflect baseline Height, Weight, and Blood Pressure. ?The Executive Director, Health and Wellness Director/Coordinator, or designee will conduct retraining to licensed nurses and registered medication aides on obtaining the baseline height, weight, and blood pressure on the Physician Plan of Care no later than 1/01/2023. ?To assist with ongoing compliance, the Health and Wellness Director or Designee will conduct an audit new residents? Physician Plan of Cares for height, weight, and blood pressure weekly for four (4) weeks.
Standard #:	22VAC40-73-380-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the social data of three of four records reviewed was updated as required. Evidence: 1. On 10-24-22 during a compliant inspection, resident #1?s social data form did not include resident?s allergy to Ace Inhibitors, Sulfa and Verapamil. This information was documented on the physical examination document dated 8-29-22, resident?s medication administration record (MARs (September and October 2022), and resident?s progress notes. 2. Resident #3?s social data was not updated to include resident?s allergy to Doxycycline, Duloxetine, Gabapentin, Metoclopramide, Prochlorperazine, Losartan, Rosiglitazone, sAXagliptin, Sitaglipfin and Levofloxacin. This information was documented on the resident?s Order Summary Report, the resident?s September and October 2022 MAR and resident?s progress notes. 3. Resident #4?s social data did not include resident?s allergy to Amlodipine, Atorvastatin, Hydrocodone, Meperidine, Morphine, Zoloft, and Iodinated Diagnostic Agents. This information is documented on the resident?s physical examination dated 8-19-22, resident?s Order Summary Report, September and October 2022 MAR and resident?s progress notes. 4. On 10-24-22 and 11-29-22, staff acknowledged the aforementioned residents? social data did not include all allergy medications.
Plan of Correction:	? The Executive Director, Health and Wellness Director or designee will review and update residents? number 1, 3, and 4 personal and social information including resident allergy information by 1/1/2023. ? The Executive Director or designee will retrain the Sales Director, Sales Managers, Health and Wellness Directors and Health and Wellness Coordinators on the residents? personal and social information requirements by 1/1/2023. ? The Executive Director, Health and Wellness Director/Coordinator, Sales Director, or designee will review new residents personal social data forms prior to move in for information, including but not limited to, allergies, and verify accuracy.. ? To assist with ongoing compliance, the Health and Wellness Director or designee will audit current residents? personal and social data information for residents residing in Assisted Living building 2 by 1/1/2023.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of four records reviewed. Evidence: 1. On 10-24-22 during a complaint inspection, resident #2?s physical dated 5-6-22 noted resident to have physical therapy (PT), once resident was settled in the facility, PT for left knee pain. This service was not documented on the resident?s ISP since admission on 4-15-22. 2. Resident #4?s record included occupational therapy (OT) services from dated 9-19-22 to 10-1-22 and physical therapy (PT) services dated 9-12-22 to 10-19-22. These services were not documented on the resident?s ISP dated 9-1-22. Resident #4?s uniform assessment instrument (UAI) dated 9-1-22 documented dressing needs as human help/physical assistance. The ISP dated 9-1-22 documented services need of walker to assist in getting dressed, human help with buttons, zippers, and shoes. Walking need assessed as mechanical help/physical assistance. The ISP documented need as, walking- unable to perform (mechanical/physical assistance), services would require staff assist X1 and the use of a wheelchair. Stairclimbing need assessed as mechanical help/physical assistance. The ISP documented resident dependent for stairclimbing, resident will be provided assistance using device of a sled by staff, physical assistance to go-up or down stairs. (resident?s transfer need is by use of a Hoyer lift).
Plan of Correction:	The following is the Plan of Correction for Brookdale Chambrel Williamsburg, Virginia regarding the Statement of Deficiencies dated 12/01/2022. 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. ?The Executive Director, Health and Wellness Director or designee will review and update the Individualized Service Plans with current care needs for resident?s number 2 and 4 by 1/1/2023. ? The Executive Director or designee will retrain the Health and Wellness Directors, Health and Wellness Coordinators on Individualized Service Plans by 1/1/2023. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit Individualized Service Plans and verify inclusion of assessed needs for residents residing in Assisted Living building number 2 by 1/30/2023. ? To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans and verify inclusion of assessed needs monthly for two months.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed the facility failed to ensure that a resident?s prescription medication was ordered for the resident and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 10-24-22, during a complaint inspection regarding missed medication, resident #1?s October medication administration (MAR) documented resident?s Lantus Solostar was not available to administer the 8:00 p.m. dosage on 10-17-22. The resident?s Lantus is prescribed for twice a day (8:00 a.m. and 8:00 p.m.) The resident?s record did not have documentation of medication being ordered prior to 8:00 p.m. on 10-17-22. The resident?s progress notes also documented medication not available on 10-17-22 for 8:00 p.m. schedule dosage. Staff #4 stated contacting the pharmacy for a refill of resident?s Lantus due to medication not being available. 2. On 10-24-22, staff acknowledged the aforementioned resident?s Lantus was not available to administer on 10-17-22 at 8:00 p.m.
Plan of Correction:	? Unable to retroactively correct missing administration of Lantus Solostar for resident 1. ? The Executive Director, Health and Wellness Director/Coordinator, or designee will retrain LPNs and RMAs on the medication management plan and availability of resident prescribed medications by 1/01/2023. ? To assist with on-going compliance, the Health and Wellness Director or designee will audit medication carts for the availability of prescribed resident medications weekly for two months.
Standard #:	22VAC40-73-650-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a physician?s order or other prescriber?s oral order was reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. On 10-24-22 during a complaint inspection, resident #1?s medication administration record (MAR) documented on September 17, 2022, an administration of twelve (12) units of Novolog. The progress notes documented a one-time order from the on called physician to administer 12 units of Novolog because resident?s blood sugar was ?HIGH?. The record did not include a signed order for this one-time administration. 2. On 10-24-22, staff acknowledged the resident?s record did not include a signed prescriber?s order for this one-time phone order for Novolog for the aforementioned resident.
Plan of Correction:	? Unable to retroactively correct resident number 1 noted medications. Health and Wellness Director or designee will contact resident number 1?s primary care provider regarding order by 1/01/2023. ? The Executive Director or designee will provide retraining to the Associate Executive Director, Assisted Living Director, Health and Wellness Directors and Health and Wellness Coordinators on having a signed resident physician order for each medication administered by 1/01/2023. ? The Health and Wellness Director or designee will retrain LPNs and RMAs on having a signed resident physician order for each medication administered by 1/01/2023. ? To assist with ongoing compliance, the Executive Director, Health and Wellness Director or designee will audit 5% of current resident medication records and orders monthly for two months.
Standard #:	22VAC40-73-680-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medications was administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule for four of four records reviewed. Evidence: 1. Resident #1?s September 2022 medication administration record documented resident?s Lantus Solostar was administered six (6) times outside the scheduled 8:00 a.m./8 p.m. dosage time. Resident?s Novolog was administered eleven (11) times outside the scheduled 7:30 a.m./11:30 a.m./5:30 p.m. dosage time. The October 2022 MAR documented Lantus Solostar was administered seven (7) times outside the 8:00 a.m./8 p.m. dosage time. The resident?s Novolog was administered twelve (12) times outside the scheduled 7:30 a.m./ 12:30 p.m./5:30 p.m. dosage time. 2. Resident #2?s September 2022 MAR documented resident?s Novolin R was administered three (3) times outside the scheduled 11:00 a.m./4:00 p.m. dosage time. The October 2022 MAR documented Novolin R administered two (2) times outside the scheduled 11:00 a.m. dosage time. Lidocaine Patch administered three (3) times outside the 8:00 a.m. dosage time. 3. Resident #3?s October 2022 MAR documented Lidoderm Patch was administered fourteen (14) times outside the 8:00 a.m. dosage time. 4. Resident #4?s October 22 MAR documented Lantus administered two (2) times outside the scheduled 9:00 a.m. dosage time.
Plan of Correction:	? Unable to retroactively give previous medications within the ordered time frame for residents 1, 2, 3, and 4. ? The Executive Director, Health and Wellness Director/Coordinator, or designee will provide retraining to Medication Aids, LPN?s, and RN?s on for the administration of medications within the ordered time frame by 1/01/2023. ? The Health and Wellness Director or designee will review staggering on medication pass times to assist with medication administration. ? To assist with on-going compliance, the Health and Wellness Director or designee will conduct weekly audits of the medication administration record for 4 weeks and then monthly for two months.