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. 20, 2022 , Sept. 22, 2022 , Sept. 28, 2022 and Oct. 14, 2022

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An on-site unannounced renewal inspection was conducted by two licensing inspectors from the Peninsula Licensing Office on 9-20-22 (ar 07:20 a.m./dep 18:20 p.m.) and day 2 (ar 09:10 a.m./dep 16:45 p.m.). The facility census was 125. A medication pass observation was conducted, first aid kit and emergency supplies reviewed, a tour of the facility was conducted, breakfast meal was observed in D-Wing building, staff and residents interviews and records were reviewed. A preliminary exit meeting was conducted on both days with the new administrator and other management team members. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. 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 #:	22VAC40-73-220-A
Description:	Based on record reviewed, document reviewed and staff interviewed, the facility failed to ensure that the requirements of 22VAC40-73-250-D-1 through D-4 regarding tuberculosis are applied to private duty personnel. Evidence: 1. On 9-20-22, C-1?s tuberculosis (TB) was dated 5-8-20. C-2?s TB was dated 2-11-20. Individuals provide private duty services for resident #5. 2. Staff #1 acknowledged the aforementioned caregivers TB was not in compliance with the requirements of the regulation for private duty personnel.
Plan of Correction:	? Tuberculosis screening report requested from the private duty agency for C1 and C2 and will be obtained by October 31, 2022. ? The Executive Director or designee will provide education for the Human Resource Manager, Business Office Manager, Associate Executive Director and Assisted Living Director on annual tuberculosis screenings for private duty personnel by 11/14/2022. ? The Human Resource Manager, Business Office Manager, Associate Executive Director and Assisted Living Director or designee will audit current private duty staff records for annual tuberculosis screening documentation by 11/14/2022. ? To assist with ongoing compliance, The Assisted Living Director or designee will audit new and current private duty personnel records monthly for two month.
Standard #:	22VAC40-73-260-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that direct care staff members maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department, Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment for two of six records reviewed. Evidence: 1. On 9/22/22, a record review of direct care staff member #8?s record did not have current first aid, document in record expired 7/2022. Staff?s date of noted as 9/20/20. 2. Staff #10?s record did not have documentation of current first aid certification within 60 days. Staff?s date of hire notes as 2/4/22 and documentation of First aid provided was dated 9/21/22. 3. On 9/22/22, staff # 1 acknowledged the aforementioned staff members? record did not include documentation of first aid.
Plan of Correction:	? Staff number 1 and 8 are not required by Virginia Department of Social Services Standards to have First Aid & CPR and neither staff member work in the clinical department or provide direct care. ? Staff number 10 will receive first aid training no later than 11/14/2022. ? The Executive Director or designee will provide education for the Human Resource Manager and Business Office Manager on CPR and First Aid requirements and scheduling necessary training prior to expiration date by 11/14/2022. ? The Human Resource Manager or designee will audit current direct care staff records for CPR and First aid by 11/14/2022. ? To assist with ongoing compliance, The Executive Director, Associate Executive Director or Designee will audit 5% of current direct care staff records for up to date CPR and First monthly for 2 months.
Standard #:	22VAC40-73-310-H
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit retain individuals with a prohibitive conditions or care needs for five of ten records reviewed. Evidence: 1. Resident #1 has been prescribed Escitalopram Oxalate and there is not psychotropic treatment plan for this medication. 2. Resident #3 has been prescribed Lexapro and Seroquel and there are no psychotropic treatment plan for these medications. 3. Resident #6 has been prescribed Ativan and there is not psychotropic treatment plan for this medication. 4. Resident #9 has been prescribed Seroquel and there is no psychotropic treatment plan for this medication. 5. Resident #10 has been prescribed Haloperidol and Ativan and there is not psychotropic treatment plan for these medications. 6. Staff acknowledged there were no treatment plans for the aforementioned residents? psychotropic medications.
Plan of Correction:	Renewal Inspection 9/20/2022-10/14/2022 The following is the Plan of Correction for Brookdale Chambrel Williamsburg, Virginia regarding the Statement of Deficiencies dated 10/14/2022. 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. ? Unable to retroactively correct initial psychotropic treatment plans for resident number 1, 3, 6,9,10. ? The Health and Wellness Director or designee will collaborate with resident number 1, 3, 6, 9, and 10?s primary care provider to initiate a Psychotropic Treatment Plan by 10/28/2022. ? The Executive Director, Health and Wellness Director/Coordinator, or designee will provide education on the psychotropic treatment plan for the licensed nurses and registered medication aides no later than 11/14/2022. ? The Health and Wellness Director or Designee will audit current residents? record that are prescribed psychotropic medications for psychotropic treatment plans by 11/14/2022. ? To assist with ongoing compliance, The Health and Wellness Director or designee with audit 5% of current residents record that are prescribed psychotropic medications for psychotropic treatment plans monthly for two months.
Standard #:	22VAC40-73-325-A
Description:	Based on record review the facility failed to ensure that fall risk ratings was updated after a fall for residents who meet the criteria for assisted living care for two of ten residents. Evidence: 1. On 9/20/22, resident #8?s record included documentation of resident falls on 7/3/22, 7/12/22, 7/30/22 and 8/2/22. The record included only one fall risk rating in the resident?s chart dated 8/22/22. 2. Resident #3?s record included documentation of falls on 6/1/22 and 6/24/22. The record did not include updated fall risk ratings documented these falls. The only fall risk assessment in the resident?s chart was dated 12/31/21. 3. Staff #1 acknowledged the aforementioned residents? record did not include the fall risk rating as required following a fall.
Plan of Correction:	? Unable to retroactively correct Fall Risk ratings for resident number 3 and 8 for month of June, July and August 2022. ? The Executive Director, Health and Wellness Director or designee will update Fall Risk ratings for resident numbers 3 and 8 no later than 10/26/2022. ? The Executive Director, Health and Wellness Director/Coordinator or designee will provide education to the licensed nurses and registered medication aides on Fall Risk rating no later than 11/14/2022. ? The Executive Director, Health and Wellness Director or designee will audit current resident records of residents with falls in 2022 for fall risk ratings by 11/14/2022. ? To assist with going compliance, The Health and Wellness Director or designee will audit 5% of current resident records with falls for updated Fall Risk rating once a month for two months.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information form was kept current. Evidence: 1. On 9/20/22, resident # 2?s personal and social information did not list the resident?s allergies. The resident?s date of admission was documented as 6/25/22. 2. On 9/22/22, resident #10?s personal and social information did not list all of the resident?s allergies. The physical examination document dated 6/24/22 noted resident allergy to Penicillin. The resident?s date of admission was documented as 6/29/22. 3. Staff acknowledged the aforementioned residents? personal and social data was not kept updated as required.
Plan of Correction:	? The Executive Director, Health and Wellness Director or designee will update residents? number 2 and 10 personal and social information with current allergies by 10/26/2022. ? The Executive Director or designee will provide education for the Sales Director, Sales Managers, Health and Wellness Directors and Health and Wellness Coordinators on the residents? personal and social information and allergies by 11/14/2022. ? The Executive Director or designee will audit current residents? personal and social information for current allergies by 11/14/2022. ? To assist with ongoing compliance, the Health and Wellness Director or Designee will audit 5% of current residents? personal and social information for allergies monthly for two months.
Standard #:	22VAC40-73-410-A
Description:	Based on resident record reviewed and staff interviewed, the facility failed to obtain an acknowledgment from the resident and/or their legal representative upon admission of receiving orientation and related information for new residents. Evidence: 1. On 9/22/22, resident #7?s orientation document was not signed and dated by the resident neither the legal representative. The resident?s date of admit noted as 5-25-22. 2. On 9/20/22, resident # 8?s record did not contain a signed acknowledgment of receiving an orientation to the facility at the time of admission. The record noted the resident?s date of admission was 2/17/22. 3. Staff #1 acknowledged the record did not include documentation of orientation for the aforementioned resident.
Plan of Correction:	? Unable to retroactively correct resident number 7 and 8 initial orientation signed acknowledgement date. ? The Executive Director, Health and Wellness Director or designee will review and update residents? number 7 and 8 orientation signed acknowledgement 10/26/2022. ? The Executive Director or designee will provide education for the Sales Director, Sales Managers, Health and Wellness Directors and Health and Wellness Coordinators on the residents? initial orientation and the acknowledgement form by 11/14/2022. ? The Executive Director, Health and Wellness Directors or designee will audit current residents? initial orientation acknowledgement form by 11/14/2022. ? To assist with ongoing compliance, The Executive Director, Health and Wellness Director or Designee will audit new residents records for initial orientation and acknowledgement form monthly for two months.
Standard #:	22VAC40-73-440-K
Description:	Based on record reviewed, document reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) for a private pay resident in an assisted living was completed as required for two residents Evidence: 1.On 9/20/22, resident #4?s uniformed assessment instrument (UAI) dated 5-6-22 was completed by a facility staff, however, the administrator or a designee did not complete the requirement for signifying approval. 2. Resident #6?s UAI dated 8/2/22, did not include administrator or a designee signature and date signifying approval. 3. Staff #1 acknowledged, the aforementioned resident?s UAIs were not completed as required.
Plan of Correction:	? The Executive Director, Health and Wellness Director or designee will review and update residents? number 4 and 6 Uniform Assessment Instrument and signatures of completion by acknowledgement 10/26/2022. ? The Executive Director or designee will provide education for the Associate Executive Director, Assisted Living Director, Health and Wellness Directors and Health and Wellness Coordinators on the residents? Uniform Assessment Instrument and signatures by 11/14/2022. ? The Executive Director, Health & Wellness Director or designee will audit current residents Uniform Assessment Instrument for signatures no later than 11/14/2022. ? To assist with ongoing compliance, The Executive Director, Health and Wellness Director or Designee will randomly audit 5% of current residents Uniform Assessment Instrument for signatures monthly for two months.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall include all assessed needs for six of ten records reviewed. Evidence: 1. On 9/20/22, resident #1?s ISP dated 9/9/22 indicated the resident is Full Code. The record included a DNR, physician signed and dated 8/12/22. 2. Resident #4?s admitting physical dated 4/1/19 documented resident is hard of hearing. The original ISP dated 4/1/19 also noted this information. The current ISP dated 5-6-22 did not include this assessed need. 3. Resident #6?s ISP date 7/29/22 did not include resident?s skilled nursing services for wound care. The record documented care for wound to right buttock near sacrum: 8/11/22 (stage 3), 8/16/22, 8/19/22, 8/23/22, 8/26/22, 8/30/22, 9/6/22 (stage 2), 9/9/22 and 9/16/22. Behavior need noted as appropriate on the uniformed assessment instrument (UAI) dated 7/14/22, 8/10/22 and 8/30/22. The ISP documented resident is resistive to care: ?reluctant to perform showering, toileting, incontinent care and grooming needs?non-compliant and reluctant with Diabetes diet?. 4. On 9/22/22 resident #7?s UAI dated 5/25/22 assessed walking need as mechanical help. This need was not addressed on the ISP dated 5/25/22. Wheeling need assesses as no help needed. The ISP documented wheeling not performed. Mobility assessed as mechanical help/human help/supervision. The mechanical need was no documented on the ISP. 5. Resident #8?s UAI dated 9/16/22 indicated the resident needed mechanical and supervision in toileting; however the most recent ISP indicated the resident needed mechanical and physical assistance by staff. 6. Resident #10?s ISP dated 6/29/22 did not include physical therapy services resident was receiving prior to receiving hospice services. Physical therapy evaluation conducted on 6/30/22 and additional visits noted in chart 7/6/22, 7/8/22 and 7/13/22. 7. Staff members acknowledged the aforementioned residents ISPs did not include all assessed needs.
Plan of Correction:	The following is the Plan of Correction for Brookdale Chambrel Williamsburg, Virginia regarding the Statement of Deficiencies dated 10/14/2022. 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 update the Individualized Service Plans with current care needs for resident?s number 1, 4, 6, 7, 8, and 10 by 11/14/2022. ? The Executive Director or designee will provide education for the Health and Wellness Directors, Health and Wellness Coordinators on Individualized Service Plans and Care needs by 11/14/2022. ? The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit current residents Individualized Service Plans and Care needs by 11/14/2022. ? To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans and care needs monthly for two months.
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of resident was met for a resident. Evidence: 1. On 9/22/22 resident #7?s physical examination signed and dated 5/16/22 documented physical therapy and occupational therapy services recommended. The record did not include documentation of these services. 2.Staff acknowledged the aforementioned resident?s record did not include documentation of physical therapy neither occupational therapy services being completed.
Plan of Correction:	? Unable to retroactively correct the admission therapy order for resident number 7. ? The Executive Director, Health and Wellness Director or designee will collaborate with residents? number 7 primary care provider regarding needs for therapy by 10/26/2022. ? The Executive Director or designee will provide education for the Associate Executive Director, Assisted Living Director, Health and Wellness Directors and Health and Wellness Coordinators on the residents? admission orders and health care services by 11/14/2022. ? The Executive Director or designee will audit current residents on the admission orders by 11/14/2022. ? To assist with ongoing compliance, The Executive Director, Health and Wellness Director or Designee will audit 5% of new resident admission orders and healthcare services monthly for two months.
Standard #:	22VAC40-73-650-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, 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. Evidence: 1. On 9-20-22, resident #4?s record did not include a physician or prescriber?s order to discontinue resident?s Apixaban (Eliquis). The resident?s September 2022 medication administration record documented resident prescribed, Apixaban 5mg tablet, two times daily for 13 doses. The MAR noted the medication was administered 7 dosages. The first dosage administered on 9/13/22 at 08:00 a.m. The lasted noted dosage on the MAR was dated 9/16/22 at 08:00 a.m. The MAR did not document the medication was discontinued. The resident?s record did not have an order documenting medication was discontinued. A review of the resident?s progress notes did not indicate medication was discontinued. 2. Resident #5?s record noted resident prescribed Remeron 15 mg at bedtime and Mirtazapine 30 mg at bedtime. The record noted signed physician?s order dated 8/9/22 for both medications. A fax dated 8/31/22 requesting clarification did not have a response. The physician?s order dated 9-12-22 noted Remeron 30 mg at bedtime. The record did not include a signed/dated prescriber?s order to discontinue Remeron 15 mg. 3. Staff acknowledged the aforementioned records did not have signed and dated orders to discontinue medications prior to the inspector?s review of the record.
Plan of Correction:	The following is the Plan of Correction for Brookdale Chambrel Williamsburg, Virginia regarding the Statement of Deficiencies dated 10/14/2022. 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. ? Unable to retroactively correct resident number 4 and 5 noted medications. Resident number 4 and 5 primary care provider will be contacted regarding orders by 10/26/2022. ? The Executive Director or designee will provide education for the Associate Executive Director, Assisted Living Director, Health and Wellness Directors and Health and Wellness Coordinators on the residents? physician orders, medication administration and related provisions by 11/14/2022. ? The Executive Director, Health and Wellness Director or designee will audit current resident?s medication records and orders by 11/14/2022. ? 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.