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: Nov. 8, 2023 , Jan. 30, 2024 and Feb. 8, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An unannounced complaint inspection was conducted by two inspectors from the Peninsula Licensing Office on 11-8-23 (Ar. 09:35 a.m./Dep 17:40 p.m.) The facility census was 58- AL-2 building 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 10-25-23 regarding allegations in the resident care and related services. Number of residents present at the facility at the beginning of the inspection: 52 (AL-2) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 11 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on documents reviewed and staffs interviewed, the facility failed to ensure that it reported the regional licensing office within 24 hours any major incident that has negatively affected the or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 11-8-23 during a medication complaint inspection, staff #1 acknowledged not reporting the medication error to the licensing department. Staff stated the report was not something that the facility would report. Staff #1 and #3 stated the incident was not reported because there was no harm to the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-H
Complaint related:	No
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 two of three records reviewed. Evidence: 1. On 11-8-23, resident #2?s October 2023?s medication administration record (MAR) included Lorazepam and Haloperidol. The record did not include a treatment plan for the prescribed psychotropic medications. 2. Resident #3?s record noted the resident prescribed Lorazepam. The resident?s record did not include a treatment plan for the prescribed psychotropic medication. 3. Staff #1 and #3 acknowledged the residents? record did not include a treatment plan for prescribed psychotropic medications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record reviewed, documents reviewed, staff interviewed and collateral interviews, the facility failed to ensure medications was administered in accordance with the physician?s order or other prescriber?s instructions for one of three records reviewed. Evidence: 1. On 11-8-23 a complaint inspection was conducted regarding a resident being administered the incorrect dosage of Lorazepam following the order being changed by the hospice agency and the resident?s representative questioning why resident #2 was constantly lethargic. On 11-8-23, resident #2?s record included an order dated 9-27-23, Lorazepam 2mg/ml, dose 0.5 ml three times a day. The record also included an order for 0.25 ml every 4 hours as needed (PRN). On 10-5-23, the resident?s Lorazepam scheduled three times a day was change. The order noted a change to the resident?s dosage. The Lorazepam oral concentrate, dose 0.5 ml give three times a was discontinued. The resident?s new order was written for Lorazepam 0.25 ml three times a day. The order was electronically signed by CS-1 and CS-2 on 10-5-23. 2. Documentation of the facility?s narcotic sheet noted on 9-30-23, the facility received a quantity of 45 dosages of 0.5ml Lorazepam, administer three times a day from a local pharmacy. The facility?s narcotic sheet noted the first dosage of the 0.5 ml Lorazepam was administered on 9-30-23 at 20:30 p.m. The facility medication staff continued to administer the 0.5 ml dose of Lorazepam until 10-23-23 at 06:00 a.m. On the resident?s October 2023 medication administration record (MAR) staff documented that the 0.25 ml dosage of Lorazepam was administered. 3. Staff #2 acknowledged medication administration staff members administered the 0.5ml dose of Lorazepam to resident #2 following the medication order change on 10-5-23. Staff stated being made aware of the medication error on 10-18-23. Staff members stated the medication remained in the refrigerator and staff continued to administer the 0.5 ml following staff #2 being informed of the medication error. 4. Staff #2 stated to the inspectors, that after being notified and addressing the medication error, staff members continued to administer the 0. 5ml dose for another 5 days. 5. The facility?s narcotic sheet documented medication staff administered the 0.25 ml PRN Lorazepam from 10-3-23 to 10-22-23. The resident?s October 2023 medication administration record (MAR) noted that the 0.25 ml PRN Lorazepam medication was administered only on 10-17-23, 10-25-23 and 10-28-23. 6. On 11-8-23, staff #2 provided the inspectors with letters for staff #5, #6, #11 and #12 documenting the medication error. The letter noted staff, ?administer 0.5ml Lorazepam to a resident in which the order read 0.25 ml. You did not follow the medication administration policy in doing so. This can be a form of neglecting to provide a service to our resident?. 7. The facility narcotic sheet noted the 0.25ml Lorazepam scheduled for three times a day was received on 10-18-23. 8. Staff #1 and #2 acknowledged resident #2 was administered the incorrect dosage of Lorazepam from 10-5-23 to 10-22-23.
Plan of Correction:	Not available online. Contact Inspector for more information.