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. 11, 2023 , Sept. 12, 2023 , Sept. 13, 2023 , Sept. 19, 2023 and Sept. 29, 2023

Complaint Related: No

Comments:

Type of inspection: Renewal An on-site renewal inspection was conducted by two inspectors on 9-11-23 (Ar 08:12 a/ dep 6:25 p) and 9-12-23 (08:37 to 4:50 p). On 9-13-23 the inspection was conducted by one inspector (Ar 07:05 a/ dep 3:05 p). The facility census on day 1 was 139. The final exit meeting will be scheduled. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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
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. Evidence: 1. On 9/13/23, resident #10?s record included an order dated 7/31/23 for Haloperidol. The record did not include a psychotropic treatment plan for this medication. 2. Staff #5 acknowledged there was no treatment plan for the resident?s psychotropic medication.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 9/13/23, resident # 8?s personal and social information did not include all the resident?s allergies. The resident?s Trazadone allergy listed on the resident?s physical examination dated 10/12/22 was not listed on the resident?s personal and social data. 2. Staff #5 acknowledged the residents? personal and social data was not kept updated as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 five of ten records reviewed. Evidence: 1. On 9/11/23, resident #2?s record documented resident receives palliative care. Occupational therapy notes dated 6/7/23, and 7/6/23 in resident?s record. These services were not documented on the resident?s ISP dated 5/3/23. The uniform assessment instrument (UAI) dated 5/3/23 noted transfer need as ?No Help?, the ISP noted this need as ?mechanical, 1 person assist with rollator to help with transfer?. Eating assessed as ?No help?, the ISP noted resident requires ?supervision during meals by dining staff and or care staff?. Walker assessed as ?No Help?, the ISP noted, ?mechanical assistance- ambulate using rollator?. Resident observed with rollator on 9/11 and 9/12/23. Wheeling assessed as ?not performed?, this need was not on the ISP. Stairclimbing assessed as mechanical help/supervision, the ISP noted, ?mechanical help/physical assistance, resident would need assistance to perform stairclimbing actions?. Mobility assessed as mechanical help/supervision, the ISP noted, mechanical assistance- requires assistance of a rollator in order to be mobile?. 2. On 9/12/23 resident #3?s physical examination dated 3/16/23 noted physical therapy and speech therapy services. The record included physical therapy notes dated 8/17/23 and 8/24/23. A physician?s order in the record was dated 8/23/23 for sacral wound care. These services were not documented on the resident?s ISP dated 4/11/23. 3. Resident #4?s record included notes of skilled nursing services on 7/11/23, 7/13/23 and 7/17/23. A physician?s order dated 8/23/23 for skilled nursing services for sacral wound was in resident?s record. Other skilled nurse?s notes in the record were dated 9/5/23, 9/7/23 and 9/12/23. This service was not documented on the resident?s ISP dated 3/22/23. 4. On 9/13/23 resident #9?s UAI dated 9/14/23, toileting need assessed as mechanical help, the ISP dated 10/17/22 noted need as ?human and mechanical assistance, use wheelchair to enter bathroom and progress to walker with PT/OT evaluation and treatment. Resident need the mechanical assistance of the handrails and walker for standing as well as human assistance?. Transferring need assessed as mechanical help, the ISP noted, human and mechanical assistance, resident ?will transfer safely from surface to surface using mechanical assistance of the wheelchair walker, grab bars and arms of furniture?; services provided by resident, direct care staff and PT/OT. 5. Resident #10?s UAI dated 7/31/23 noted resident?s behavior was appropriate. The ISP dated 7/31/23 noted resident is aggressive, agitated, and barricading door. Resident has a 1:1 companion for safety. 6. Staff members acknowledged the residents ISPs did not include all assessed needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. On 9/13/23, resident #8?s ISP was last signed and date by resident?s representative on 7/12/22. The outcome expected outcome and date of expected outcomes date was dated 4/26/23. 2. Staff #5 acknowledged the resident?s record did not have a current ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 9/11/23 during a tour of the building 2/Crossing, the menu posted was dated 9/10/23 to 9/16/23. The snack menu posted was dated 8/13/23 to 9/9/23. 2. Staff #6 and #14 acknowledged the menus posted for meals and snack were not current.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 9/11/23 during the medication pass observation with staff #12, resident #2?s September 2023 medication administration record (MAR) noted resident?s Sinemet Oral Tablet 25-100 mg tablet- ?give 1.5 tablet by mouth four times a day for Parkinson?s sleep disturbance related to Parkinson?s disease. Md prescribed times 6am, 10am, 2pm and 6p.m. start date 6/8/2023. The resident?s record did not have a signed and dated physician?s order. The resident?s MAR also noted Trazadone 0.5 mg was discontinued on 5/30/23 and Trazadone 1.0 mg was discontinued on 6/2/23. The record did not have these discontinued orders. 2. On 9/11/23 during the medication pass observation with staff #12, Refresh eye drops was on resident #1?s nightstand. The resident?s record did not have a physician?s order for the eye-drop and no order for resident to keep medication at bedside. 3. Staff acknowledged the records did not have signed and dated orders to discontinue medications prior to the inspector?s review of the record. And there was no order for resident to keep medication at bedside.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-B
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 include the name of the resident, the date of the order, the name of the drug, route, dosage strength, how often the medication is to be given, and identify the diagnosis condition, or specific indications for administering each drug. Evidence: 1. On 9/11/23 during the medication pass observation with staff #12, resident#2?s September 2023?s medication administration record (MAR) did not have a diagnosis for Celexa. The resident?s physician?s order dated 8/4/23 also did not have a diagnosis for this drug. 2. Staff acknowledged that the resident?s record did not have a diagnosis for the Celexa drug prescribed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 9/12/23, during a tour of the main building with staff #2 and #9, the hot water temperature was checked in room #305. The temperature reading was 90 degrees F. 2. Staff acknowledged the water temperature was not within the required temperature range.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-930-B
Description:	Based on observation and staff interviewed, the facility failed to ensure staff was able to determine the origin of the signal for the call system. Evidence: On 9/11/23, during a tour of the safe, secure unit in The Crossing building, the call bell in the common use bathroom near the activity room was pulled at 9:49. The inspectors waited for someone to respond. At 9:59, the inspector inquired of staff #11 why no one responded to the call bell being pulled. Staff #11 inquired of another staff member why the pager was not answered. It was observed that the pager was not any of the staff persons on the unit. The pager was attached to the computer stand on top of the medication cart. When staff #11 checked the pager, it was stated that the volume was turned down and the battery was also low. The staff members did not know the call bell had been activated in the common area bathroom.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all times. Items with expiration dates must not have dates that have already passed. Evidence: 1. On 9/12/23, the first aid kit in the Clarebridge building was checked with staff #4. The first aid kit did not have extra flashlight batteries and the ointment was dated 1/2023. The check list was last dated 8/7/23. 2. On 9/13/23, the first aid kit on the vehicle was checked with staff #10. The antiseptic ointment was dated 1/22. The check list was last dated 7/5/23. 3. Staff acknowledged the items in the first aid kit were expired.
Plan of Correction:	Not available online. Contact Inspector for more information.