Virginia DSS · Assisted Living Facility

Brookdale Chambrel Williamsburg

📍 3800 TREYBURN DRIVE, Williamsburg, VA, 23185

ID 25750Two Year licenseActive
19
Inspections
On record
14
With violations
Visits that cited something
5
Clean visits
Nothing cited
72
Violations cited
Individual findings
38
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Brookdale Chambrel Williamsburg was inspected 19 times between November 2, 2020 and October 6, 2025 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 72 violations under 38 distinct standards. 9 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 17 of these 19 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
10/28/2027
Administrator
Joel Abercrombie
Licensing inspector
Coy Stevenson
Inspector phone
(804) 972-4700
Approved for
Assisted Living · Special Care Unit

Inspection History

19

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

October 6, 2025Complaint survey0 violations
Inspection dates
10/06/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection related to a complaint was conducted on November 06, 2025. 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 October 24, 2025, regarding allegations in the area(s) of: PERSONNEL; RESIDENT CARE AND RELATED SERVICES Number of resident records reviewed: 1 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: The resident identified in the complaint, along with other residents living at the facility, were observed interacting with each other and staff. These interactions were appropriate. The residents were observed during meal service. The residents were appropriately dressed and groomed for the time of day, weather conditions, and activities they were engaged in. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 6, 2025Inspection0 violations
Inspection dates
10/06/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection of the facility was conducted on October 06, 2025, between approximately 9:30 AM – 3:30 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 135 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medications being prepared and given to residents was observed. Interactions between staff and residents and residents with each other were noted to be appropriated. Residents observed were noted to be appropriately groomed and dressed for the time of day and activities they were engaged in. There were no signs of the building and surrounding grounds being in disrepair or creating unsafe conditions or conditions for insect infestations. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2024Inspection4 violations
Inspection dates
09/24/2024; 09/25/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/24/2024 from 8:30 am to 3:15 pm and 09/25/2024 from 10:50 am to 1:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 128 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed on 4 residents. The following were reviewed: resident and staff records, emergency preparedness drills, medication carts, and the staff schedule. Water temperature was measured, and the call bell system was monitored. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-90-40-B
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff #5 (hired 09/26/2023) did not have a completed history record report in their staff record.
Plan of correction
Unable to retroactively correct having a copy of the Virginia State Police criminal history report that was completed for Staff #5 in the staff record. HR Manager has completed a new Virginia State Police criminal history report for Staff #5 and placed the results of the report in the staff record. The date of this correction is September 24, 2024. Executive Director (ED), or designee will retrain HR Manager on the process of accurately filing completed criminal history reports. This training will be completed by October 15, 2024. To assist with ongoing compliance, the ED or designee will audit fifty percent (50%) of newly hired staff records weekly for four (4) weeks.
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive individualized service plan should include a description of identified needs and date identified based upon the UAI, admission physical examination, and other sources.
Evidence
  1. Resident #1 utilizes an electric scooter and has a NAS diet; however, their use of the electric scooter and their special diet were not documented in their ISP (dated 03/13/2024).
  2. Resident #3 utilizes an assistive device (mounted device from floor to ceiling); however, the assistive device was not documented in their ISP (dated 07/02/2024). Additionally, Resident #3 has a DNR (dated 07/24/2024); however, their ISP indicates the resident as a Full Code.
  3. Resident #5 admitted to hospice services on 07/30/2024; however, it is not documented on their ISP (dated 11/01/2023).
Plan of correction
Unable to retroactively correct ISP to accurately reflect assistive devices and services for residents #1, #3, and #5 prior to the date of inspection. Health and Wellness Director (HWD) has corrected the ISP for residents #1, #3, and #5 to accurately reflect assistive devices and services. The date of this correction is September 30, 2024. Executive Director (ED), HWD or designee will retrain licensed nursing associates on the process of accurately documenting changes to the resident’s care plan on the ISP. This training will be completed by October 15, 2024. To assist with ongoing compliance, the HWD or designee will audit ten percent (10%) of residents’ ISP’s weekly for four (4) weeks.
22VAC40-73-990-C
Based on interview and record review, the facility failed to document all staff currently on duty on each shift participate in an exercise in which the procedures for resident emergencies are practiced at least once every six months.
Evidence
  1. The facility was unable to provide documentation that all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies are practiced at least once every six months.
Plan of correction
Unable to retroactively correct documentation of resident emergency drills to reflect that all staff on each shift participated in the drill. Maintenance Director will follow process of conducting the resident emergency drills in conjunction with the fire drills, which will ensure that all staff on each shift participate in the drill every six months. Executive Director (ED), or designee will retrain associates on the process of accurately documenting resident emergency drills. This training will be completed by October 15, 2024. To assist with ongoing compliance, the ED or designee will audit completed resident emergency drills for the next two months.
22VAC40-73-930-D
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. There was no documentation of 2-hour rounding for Resident #4, Resident #9, Resident #10, and Resident #11 residing within the Crossings, a safe, secure unit.
Plan of correction
Unable to retroactively correct documentation of two hour rounds completed for Residents #4, #5, and #10 in the Crossings, a safe, secure, unit. Health and Wellness Director (HWD) has implemented an electronic nighttime two hour rounding process in electronic record. Executive Director (ED), HWD or designee will retrain licensed nursing associates on the process of accurately documenting two hour rounds in electronic record. This training will be completed by October 15, 2024. To assist with ongoing compliance, the HWD or designee will audit ten percent (10%) of residents’ two hour rounding log for four (4) weeks.
August 8, 2024Complaint survey0 violations
Inspection dates
08/08/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/08/2024 from 11:05 am to 12:08 pm. 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 07/16/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 132 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 23, 2024Inspection1 violation
Inspection dates
05/23/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/23/2024 from 10:45 am to 12:02 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two self-reported incident was received by VDSS Division of Licensing on 05/07/2024 and 05/09/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 148 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-reports of non-compliance with standard(s) or law. However, violation(s) not related to the self-reports but identified during the course of the investigation can 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive individualized service plan should include a description of identified needs and date identified based upon the UAI and admission physical examination.
Evidence
  1. Resident #3 self-administers their medications; however, the ISP for Resident #3 (dated 05/02/2024) indicates the resident “requires assistance with medications” to “be stored, ordered, and administered by nursing staff.”
Plan of correction
Unable to retroactively correct ISP to accurately reflect medication management for resident #3 prior to the date of inspection. Health and Wellness Director (HWD) has corrected the ISP for resident #3 to accurately reflect the medication management plan. The date of this correction is May 29, 2024. Executive Director (ED), HWD or designee will retrain licensed nursing associates on the process of accurately documenting changes to the resident’s care plan on the ISP. This training will be completed by May 31, 2024. To assist with ongoing compliance, the HWD or designee will audit ten percent (10%) of residents’ ISP’s weekly for four (4) weeks.
May 2, 2024Complaint survey1 violation
Inspection dates
05/02/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2024 from 11:25 am to 12:25 pm. 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 04/23/2024 regarding allegations in the area(s) of: Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 145 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: Reviewed resident rounding logs for 3 residents from March 2024 to present. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-930-D
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. Resident #1 fell on the evening of 3/30/2024; however, there was not documentation of 2-hour rounding on the evening of 3/30/2024 or early morning of 3/31/2024.
  2. The documentation for Resident #1 indicates 2-hour rounding for the 11p-7a shift was completed on the 3/11/24 and 3/17/24-3/20/2024 in March 2024.
  3. The ISP for Resident #1 (dated 10/24/2023) indicates the staff will check on Resident #1 “every 2 hours during asleep times and frequently throughout the awake times.”
Plan of correction
Unable to retroactively correct missing documentation of two-hour night checks for March 2024 for resident #1. Health and Wellness Director (HWD) has transitioned the two (2)-hour night checks from paper record to electronic documentation, with the associate signing the completion of the two (2) hour night checks for current memory care residents. The date of this transition will be implemented on May 10, 2024. HWD or designee will retrain current nighttime memory care associates on the importance of two (2)-hour checks and the process of electronic documentation during overnight hours. To assist with ongoing compliance, the Executive Director, HWD or designee will review the electronic documentation of two-hour night checks for current memory care residents weekly for four (4) weeks.
May 2, 2024Inspection0 violations
Inspection dates
05/02/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2024 from 11:25 am to 12:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/29/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 145 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 4, 2024Inspection1 violation
Inspection dates
04/04/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/04/2024 from 10:08 am to 11:00 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/11/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 143 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Additional Comments/Discussion: A medication cart was reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Resident #1’s nightly Gabapentin 300 mg capsule was not available for administration on 3/2/2024-3/11/2024.
Plan of correction
Staff will be re-educated by the Health and Wellness Director on the importance of giving medication within the 2 hour window I.E. if the medication is due at 9am they have from 8am to 10am to give the medication. Weekly cart audits will be conducted to ensure that the ordered medication is on hand to prevent delay.
November 8, 2023Complaint survey3 violations
Inspection dates
11/08/2023;01/30/2024;02/08/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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
22VAC40-73-70-A
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 published by VDSS.
22VAC40-73-680-D
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 published by VDSS.
22VAC40-73-310-H
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 published by VDSS.
October 30, 2023Complaint survey5 violations
Inspection dates
10/30/2023;01/30/2024;01/31/2024;02/08/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An on-site complaint inspection was conducted by two inspectors from the Peninsula Licensing Office on 10-30-23. Ar. 09:28 a.m./dep 17:00 p.m. 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 9-26-23 regarding allegations in the of resident care and related services. Number of residents present at the facility at the beginning of the inspection: C- main building 52 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: 3 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 did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s comprehensive individualized service plan (ISP) included all assessed needs for one of three records reviewed.
Evidence
  1. On 10-30-23, resident #3’s individualized service plan (ISP) dated, 8-21-23 documented resident was assessed as a Do Not Resuscitate (DNR). The ISP noted “life saving measures WILL NOT be performed in the event of a cardiac or respiratory event”. The record included a copy of a blank DNR form. There was no documentation of a signed DNR document in the resident’s record. The resident’s date of admit noted as 8-24-23.
  2. Staff acknowledged the resident’s record did not include a signed and dated DNR document.
Plan of correction
Not published by VDSS.
22VAC40-73-310-H
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 one of three records reviewed.
Evidence
  1. On 10-30-23, resident #1’s September and October 2023 medication administration records (MAR)s documented resident administered Mirtazapine and Wellbutrin. The record did not include a treatment plan for these prescribed psychotropic medications.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure resident’s individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident's condition for one of three records reviewed.
Evidence
  1. 10-30-23, resident #1’s individualized service plan (ISP) in the record was last updated on 8-24-22. The resident’s date of admit noted as 9-15-20.
  2. Staff #1 acknowledged the resident’s ISP was not review and or updated.
Plan of correction
Not published by VDSS.
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information required in subsection 380-A of the regulations was kept current for one of three records reviewed.
Evidence
  1. On 10-30-23, resident #3’s personal and social information document noted in the advance directive section, the resident had a Do Not Resuscitate (DNR). The allergy section noted the resident did not have any allergies. The resident’s physical examination document dated 8-21-23 noted resident’s allergy. The resident’s individualized service plan (ISP) dated 8-24-23 noted resident allergy to Citalopram, Erythromycin, Hydrocodone, Avelox, and Lyrica. The record did not include a signed and dated DNR document. The resident’s date of admit was noted as 8-24-23.
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for one of three records reviewed.
Evidence
  1. On 10-30-23, resident #1’s record did not include documentation of a current tuberculosis (TB) assessment. The TB documents in the record were dated 1-15-21 and 1-11-22. Resident’s date of admit noted as 9-15-20.
Plan of correction
Not published by VDSS.
September 11, 2023Inspection10 violations
Inspection dates
09/11/2023;09/12/2023;09/13/2023;09/19/2023;09/29/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORTNone
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 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 1was 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
22VAC40-73-650-A
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 published by VDSS.
22VAC40-73-450-C
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 published by VDSS.
22VAC40-73-980-A
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 published by VDSS.
22VAC40-73-380-B
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 published by VDSS.
22VAC40-73-930-B
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
  1. 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 published by VDSS.
22VAC40-73-450-F
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 published by VDSS.
22VAC40-73-860-G
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 published by VDSS.
22VAC40-73-650-B
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 published by VDSS.
22VAC40-73-310-H
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 published by VDSS.
22VAC40-73-610-B
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 published by VDSS.
March 6, 2023Complaint survey2 violations
Inspection dates
03/06/2023,05/05/2023,05/09/2023,05/25/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint An unannounced complaint inspection was conducted on 3-6-23 (Ar 9:45 am/dep 5:20 pm). 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 1-25-23 regarding allegations in the resident care and related services: nutrition-buildings and grounds-resident care needs. Number of residents present at the facility at the beginning of the inspection: 128 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: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive service plan included all assessed needs.
Evidence
  1. On 3-6-23, resident #2’s uniform assessment instrument (UAI) dated 2-22-23 documented mobility need assessed as mechanical help/physical assistance. The individualized service plan (ISP) signed by the legal representative on 2-11-23 documented, resident needed, “one person assistance to get to doctor appointments and place to place”.
Plan of correction
The following is the Plan of Correction for Brookdale Chambrel Williamsburg, Virginia regarding the Statement of Deficiencies dated 5/25/2023. 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 number 2 by 6/1/2023. • 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 6/15/2023. • The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit current residents Individualized Service Plans and Care needs by 6/30/2023. • 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.
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s personal and social data was kept current.
Evidence
  1. On 3-6-23 during a compliant inspection, resident #1’s personal social data form documented resident’s code status as “DNR”. The individualized service plan (ISP) dated 5-12-22 documented the resident was a “Full Code”. Collateral interview revealed resident is a full code.
  2. On 3-6-23, staff acknowledged the aforementioned resident’s personal and social data form was not updated.
Plan of correction
• The Executive Director, Health and Wellness Director or designee will update resident number 1 personal and social information with “Full Code” by June 1, 2023. • 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 DNR/Full Code by June 15, 2023.. • The Health and Wellness Director or Designee will audit all current residents’ records personal and social information for DNR by June 30, 2023. • To assist with ongoing compliance, the Health and Wellness Director or Designee will audit 5% of current residents’ personal and social information for DNR/Full Code monthly for two months.
March 6, 2023Complaint survey0 violations
Inspection dates
03/06/2023,05/05/2023,05/12/2023,05/
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint An unannounced complaint inspection was conducted on 3-6-23 (Ar 9:45 am/dep 5:20 pm). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An on-line complaint was received by VDSS Division of Licensing on 2-16-23 regarding allegations in the resident care and related services and increase services charges. Number of residents present at the facility at the beginning of the inspection: 128 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 9 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 24, 2022Complaint survey7 violations
Inspection dates
10/24/2022,11/29/2022,12/01/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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
22VAC40-73-310-H
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.
22VAC40-73-320-A
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.
22VAC40-73-450-C
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.
22VAC40-73-650-C
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.
22VAC40-73-680-C
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.
22VAC40-73-380-B
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.
22VAC40-73-640-A
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.
September 20, 2022Inspection10 violations
Inspection dates
09/20/2022,09/22/2022;09/28/2022;10/14/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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
22VAC40-73-410-A
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.
22VAC40-73-440-K
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.
22VAC40-73-450-C
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.
22VAC40-73-325-A
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.
22VAC40-73-470-A
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.
22VAC40-73-650-A
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.
22VAC40-73-260-A
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.
22VAC40-73-380-B
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.
22VAC40-73-310-H
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.
22VAC40-73-220-A
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.
March 7, 2022Inspection6 violations
Inspection dates
03/07/2022; 03/08/2022; 03/18//2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 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
22VAC40-73-310-H
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
22VAC40-73-450-C
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
22VAC40-73-650-A
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
22VAC40-73-680-I
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
22VAC40-73-680-K
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. 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
22VAC40-73-450-F
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
September 15, 2021Inspection17 violations
Inspection dates
9/15/2021; 9/16/2021; 9/30/2021; 10/7/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
A renewal inspection was initiated on 9-15-2021 and concluded on 10-7-2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 105. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed five resident records, five staff records, activities calendar, staff schedules, fire and health inspections, healthcare oversight, nutrition and pharmacy reports and fire and emergency preparedness submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10-7-2021. An exit interview was conducted with the Administrator, Assistant Executive Director and other staff members on 9-30-2021 and 10-7-2021. where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-290-A
Based on document reviewed, the facility failed to ensure the written work schedule that is maintained for two years indicated whomever is in charge at any given time.
Evidence
  1. The written September 2021 staff schedule for building AL-1 did not indicate whomever is in charge at any given time.
  2. On 9-30-21 during the exit, staff #1 stated the staff person in charge is posted in each building.
Plan of correction
1. The written work schedule for AL1 has been updated to reflect whomever is in charge at any given time. 2. The Executive Director or designee will re-educate AL Director on state regulation and Brookdale policy on staff schedules. 3. Responsible party: Executive Director 4. The Executive Director or designee will audit associate work schedule monthly to ensure names, job classifications and person in charge listed. 5. Completion date: December 31, 2021 and ongoing.
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care need for four of five sampled resident’s record
Evidence
  1. Resident #2’s August and September 2021 medication administration record (mar) documented resident prescribed Zyprexa, start date 6-19-21. Resident’s record did not include a signed treatment plan for psychotropic medication.
  2. Resident #3’s signed physician’s order dated 8-3-21 and August 2021 mar documented Mirtazapine, with a start date of 3-17-20. Resident’s record did not include a signed treatment plan for psychotropic medication.
  3. Resident #4’s August 2021 mar documented Zoloft with a start date of 5-21-21. Resident’s record did not include a signed treatment plan for psychotropic medication.
  4. Resident #4’s August 2021 mar documented Cymbalta (start date of 8-3-21); Trazadone (start date 8-2-21) and Buspirone (start date 8-2-21). Resident’s record did not include a psychotropic treatment plan.
  5. On 9-30-21, during the exit meeting, the facility was given the opportunity to forward documents to the inspector. Staff #1 forwarded inspection documents on 10-1-21 and 10-4-21. Documentation of the aforementioned residents’ psychotropic treatment plans were not included in documents received following the exit on 9-30-21.
Plan of correction
1. A Psychotropic Treatment Plan for Zyprexa will be received by physician and documented in chart for Resident #2 by November 30, 2021. A Psychotropic Treatment Plan for Mirtazapine will be received by physician and documented in chart for Resident #3 by November 30, 2021. A Psychotropic Treatment Plan for Zoloft, Cymbalta, Trazodone and Buspirone will be received by physician and documented in chart for Resident #4 by November 30, 2021. 2. Resident records will be audited for requirement of psychotropic treatment plans and obtained from the physician as necessary. The District Clinical Director or designee will educate the Health and Wellness Director on appropriate diagnosis and treatment plans of psychotropic medications per state regulation 22VAC40-73-(5)-310-H. 3. Responsible Party: Health and Wellness Director 4. The Health and Wellness Director or designee will audit 25% of resident charts for psychotropic treatment plan documentation for each psychotropic medication. The audit results will be brought to the Quality Assurance meeting. 5. Completion date: December 31, 2021 and on-going.
22VAC40-73-210-B
Based on record review and staff interview, the facility failed to ensure one of five sampled staff record documented at least 18 hours of annual training.
Evidence
  1. Staff #8’s training record documented 4.25 hours of the required 18 hours of annual training. Staff record documented staff’s date of hire 6-17-19.
  2. On 9-30-21 during the exit, staff #1 and #2 acknowledged staff’s record did not include 18 hours of training.
Plan of correction
1. Staff #8 will complete the additional 13.5 hours of annual training by December 31, 2021. 2. HR Manager will audit Employee Files to ensure Direct Care Staff have 18 hours of annual training by December 31, 2021. Employees will complete the training per state requirement and Brookdale policy. 3. Responsible Party: HR Manager 4. HR Manager and/or designee will audit 20% of Associate Training Files monthly for annual compliance of training requirements. 5. Completion date: December 31, 2021 and on-going
22VAC40-73-470-A
Based on record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met for one of five sampled records.
Evidence
  1. Resident #1’s admitting physical examination signed and dated 5-3-21 documented occupational therapy evaluation and treat. The resident’s individualized service plan did not document resident’s receiving services. The resident’s progress notes did not document resident receiving services.
  2. On 9-30-21, physician’s order for occupational therapy evaluation and treatment not being completed was addressed with staff #1 and #2.
Plan of correction
1. Resident #1 Occupational Evaluation and Treatment was completed on 05/27/2021. Resident moved in 5/14/2021. 2. Resident records will be audited for ordered healthcare service needs. The audit will include the ISP and documentation in notes. The clinical nursing staff will be re-educated on ISP and clinical documentation. 3. The Health and Wellness Director or designee will audit 10% of resident records monthly to acknowledge the residents assessed needs have been included/updated on ISP and documented in notes. 4. Responsible party: Health and Wellness Director. 5. Correction Date: December 31, 2021 and ongoing
22VAC40-73-700-1
Based on record review and staff interview, the facility failed to ensure when oxygen therapy is provided, the facility shall have a valid physician’s or other prescriber’s order that included all of the regulation requirements for one of five sampled records.
Evidence
  1. Resident 3’s individualized service plan (ISP) dated 8-27-21 and progress notes dated 8-27-21 at 14:30 p.m. documented resident’s use of oxygen via nasal cannula. Resident’s record did not include a physician’s order for oxygen therapy.
  2. On 9-30-21 during exit, staff #1 and #2 inspector addressed resident’s record not having physician’s order for oxygen. Staff #1 sent additional documents on 10-1-21 but documents received did not included physician’s orders for resident #3’s oxygen therapy.
Plan of correction
1. Resident #3 discharge summary and discharge instructions dated 8/27/21 included documentation for Oxygen therapy to include oxygen source, delivery device and flow rate 2.For residents receiving oxygen, records will be audited for valid physician/prescriber orders for oxygen and orders will be obtained if necessary. The clinical nursing staff will be re-educated on valid physician and/or prescriber orders for oxygen therapy. 3. Responsible party: Health and Wellness Director. 4. The Health and Wellness Director or designee will audit 10% of resident records monthly for valid physician/prescriber orders when oxygen therapy is administered. 5. Correction date: December 31, 2021 and ongoing.
22VAC40-73-450-D
Based on record review, the facility failed to ensure when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan (ISP) for one of five sampled records.
Evidence
  1. Resident #4’s individualized service plan (ISP) document hospice services with an identified need date of 8-3-21. However, the services provided are not documented on the service plan.
  2. On 9-30-21 during the exit, staff #1 and #2 acknowledged the ISP did not include the specific hospice services being provided.
Plan of correction
1. The ISP for Resident #4 will be updated to reflect current assessed needs including hospice services. 2. Resident ISPs will be audited for need to include hospice care services. Hospice care services will be included on the ISP for resident under hospice care. The clinical nursing staff will be re-educated on ISP documentation when hospice services are rendered. 3. The Health and Wellness Director or designee will audit 10% of resident records to acknowledge the residents assessed needs have been included/updated on ISP. 4. Responsible party: Health and Wellness Director. 5. Correction date: December 31, 2021 and ongoing.
22VAC40-73-930-A
Based on observation and staff interviews, the facility failed to ensure staff was able to receive the alert from the facility’s signaling device.
Evidence
  1. On 10-7-21 during a tour of the facility, the call bell was pulled in the bathroom in room #306 located in building #3, 3rd floor (on the safe, secure) unit at 11:39 a.m. At 11:45 a.m. there was no response, the inspector inquired of staff #10 regarding the call bell system. Staff #11 was also asked why there was no response. Staff #12 was the individual with the pager, but stated not hearing the signal. Further conversation with staff members determined, staff #12 possessed the only pager on the unit. The other care staff did not have pagers and therefore did not respond to the signal alert for room #306.
  2. Staff #2 acknowledged there was only one pager available on the unit.
Plan of correction
1. A 2nd pager was programmed and given to Staff #11 on the day of inspection, October 7, 2021, so all direct care staff in unit would receive alerts when a resident needs assistance. 2. The Executive Director or designee will audit individual units for adequate pagers for staff; pagers will be purchased if necessary. Direct Care Staff will be re-educated on provisions for signaling and call systems. 3. Responsible Party: Executive Director 4. The Executive Director or designee will complete monthly audits on pagers to verify pagers are present and in good working condition. 5. Completion date: December 31, 2021 and on-going
22VAC40-73-210-F
Based on record review and staff interview, the facility failed to ensure two of five sampled staff record documented at least two hours of infection control and prevention and at least four hours of topics related to resident’s mental impairments.
Evidence
  1. Staff #6’s training record documented 2 hours of the required 4 hours of topics related to resident’s mental impairments; staff’s date of hire, 3-11-20. Staff #8’s record did not include documentation of topics related to resident’s mental impairments; staff’s date of hire, 6-17-19.
  2. Staff #7’s training record documented 1.50 hours of infection control and prevention training; staff’s date of hire 5-8-18.
  3. On 9-30-21 during the exit, staff #1 and #2 acknowledged staff’s record did not include required hours of training.
Plan of correction
1. Staff #6 will complete the additional 2 hours of mental impairment training by December 31, 2021. Staff #8 will complete 4 hours of mental impairment training by December 31, 2021. Staff #7 will complete the additional .5 hours of infection control training by December 31, 2021. 2. HR Manager or designee will audit Employee Files for completion of required hours of Infection Control Training and mental impairment training. Employees will be supervised to complete the required training per state regulation and Brookdale policy. 3. Responsible Party: HR Manager 4. HR Manager and/or designee will audit 20% of Associate Files monthly for annual Infection Control training and mental impairment training per state regulation and Brookdale policy. 5. Completion date: December 31, 2021 and on-going
22VAC40-73-870-A
Based on observation and staff interviews, the facility failed to ensure the interior of the building was maintained in good repair and kept cleaned and free of rubbish.
Evidence
  1. On 10-7-21, during a tour of building #2’s (safe, secure, unit), the following was observed in room #C-15: (a) the carpet contained brown and grey particles; (b) a large stained area was located near the outlets on the left wall; (c) the base board is separating from the wall and three scrapes/ scratch marks approximately 6 inches long on the lower left wall and (d) the window contained dark colored debris.
  2. Staff #2 and #10 acknowledged, room #C-15 was not maintained in good repair and kept cleaned.
Plan of correction
1. The Maintenance Director and/or designee will have apartment #C-15 carpet replaced, walls repaired and painted, windows cleaned, apartment cleaned and restored back to good condition by December 31, 2021. 2. The Maintenance Director or designee will inspect resident units and interior of building for maintenance and rubbish. Areas found to be needing of repair or cleaning will be corrected. The Executive Director or designee will provide education for Maintenance Director and Maintenance Technician’s on maintenance of interior and exterior to be kept in good repair, clean and free of rubbish per state regulations and Brookdale policy. 3. Responsible Party: Maintenance Director 4. The Maintenance Director and/or designee will visually inspect 25% of resident apartments monthly to ensure apartments are kept in good repair, kept clean and free of rubbish. 5. Completion date: December 21, 2021 and ongoing.
22VAC40-73-260-A
Based on record review and staff interview, the facility failed to ensure one of five sampled staff records included documentation of current certification in first aid.
Evidence
  1. Staff #8’s training record did not include documentation on current certification in first aid.
  2. On 9-30-21, during the exit, staff #1 stated the cards were not printed. The facility was given the opportunity to forward documents to the inspector. Staff #1 forwarded inspection documents on 10-1-21 and 10-4-21. Documentation of staff #8’s certification in first aid was not included in documents received following the exit on 9-30-21.
Plan of correction
1. Staff #8 will complete a first aid training course by December 31, 2021. 2. The HR Manager or designee will audit clinical employee files for proof of first aid training. Employees in need of first aid training will complete the training by December 31, 2021. 3. Responsible Party: HR Manager 4. HR Manager and/or designee will audit 20% of Associate Training Files monthly for compliance of first aid training requirements per state regulations. 5. Completion date: December 31, 2021 and on-going
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing for one of five sampled records.
Evidence
  1. Resident #1’s physician’s order dated 8-10-21, documented “STOP Diclofenac”. Resident’s August medication administration record (mar) documented medication was administered seven times following the discontinuation order.
  2. On 9-30-21 during the exit, staff #1 and #2 acknowledged documentation of the medication’s administration following the discontinued order.
Plan of correction
1. Resident #1 physician order for diclofenac has been clarified and, physician and responsible party were informed of the administration of medication for an additional 7 doses. 2. Resident records were audited for appropriate administration of medications in accordance with the physician/prescribers instructions. The clinical staff will be re-educated on medication administration in accordance with the physician’s/prescriber’s instructions and consistent with the standards of practice of the Virginia Board of Nursing. 3. The Health and Wellness Director or designee will audit 10% of resident records/MARs monthly for accurate administration of medications. 4. Responsible party: Health and Wellness Director. 5. Completion date: December 31, 2021 and ongoing.
22VAC40-73-250-D
Based on record review and staff interview, the facility failed to ensure one of five sampled staff records included documentation of a subsequent tuberculosis (TB) evaluation and report.
Evidence
  1. Staff #8’s training record did not include documentation of an annual TB evaluation and report; staff’s date of hire, 6-17-19.
  2. On 9-30-21 during the exit, staff #1 and #2 acknowledged staff’s record did not include an annual TB report.
Plan of correction
1. A Tuberculosis screening was completed on Staff #8 on October 8, 2021. 2. The Executive Director and/or designee will re-educate the HR Manager on annual tuberculosis screenings per state regulations. The HR Manager or designee will audit current staff records for annual tuberculosis screening documentation per state regulations. 3. Responsible Party: HR Manager 4. The HR Manager or designee will audit 25% of staff records monthly for compliance of annual tuberculosis screening. 5. Completion date: December 31, 2021 and on-going
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the resident’s individualized service plan (ISP) for four of five sampled records included all assessed needs.
Evidence
  1. Resident #1’s record documented physical therapy evaluation and services on 9-9-21. This service was not documented on the resident’s ISP, last signed and dated 5-14-21.
  2. Resident #2’s record documented physician’s order dated 9-7-21 and Progress Notes dated 9-7-21 documented, home health nursing services for sacral ulcers, home health nursing notes document services began 9-8-21. Resident also began physical therapy services on 9-8-21. These services were not documented on the resident’s ISP dated 3-22-21.
  3. Resident #3’s “Client Coordination Notes Report” documented physical therapy services evaluated and began on 9-8-21 and Occupational services evaluated and began on 9-9-21. These services were not documented on resident’s ISP dated 8-27-21.
  4. Resident #5’s Progress Notes and Order Summary Report documented the following allergies: (a) Reglan, (b) Wellbutrin and (c) Zyprexa. These allergies were not documented on the ISP dated 7-30-21.
  5. On 9-30-21, information not documented on the aforementioned resident’s ISP were reviewed with staff #1 and #2.
Plan of correction
The following is the Plan of Correction for Brookdale Chambrel Williamsburg regarding the Statement of Deficiencies dated September 15, 16 and 30, 2021. 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. 1. The ISP for Resident #1, #2, and # 3 will be updated to reflect current assessed needs. The ISP for Resident #5 was updated to reflect allergies. 2. Resident ISPs will be 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 ISP documentation. 3. The Health and Wellness Director will audit 10% of resident records monthly to acknowledge the residents assessed needs have been included/updated on ISP. 4. Responsible party: Health and Wellness Director. 5. Correction date: December 31, 2021 and ongoing
22VAC40-73-980-A
Based on observation and staff interviews, the facility failed to ensure the first aid kit in each building was completed. Items with expiration dates must not have dates that have already passed.
Evidence
  1. An examination of the first aid kit in Building #3’s (safe, secure unit) with staff #11, determined the following items were missing: (a) Band-Aids in assorted sizes; (b) blankets, either disposable or other; (c) flashlights and extra batteries; (d) cold pack; (e) thermometer; (f) triangular bandages.
  2. An examination of the first aid kit on the first floor of Building #3 with staff #13, determined the hand sanitizer had an expiration date of 9-24-20.
  3. On 10-7-21, during the on-site exit, staff #2 acknowledged the first aid kits were not completed and the hand sanitizer had expired.
Plan of correction
1. The Band-Aids in assorted sizes, blanket, flashlight with extra batteries, cold pack, thermometer and triangular bandage in Building #3 3rd Floor (secure unit) and the hand sanitizer in Building #3 first floor were replaced on October 26, 2021. 2. An Audit of First Aid Kits will be completed for item not expired and kits are complete. First Aid Kit items will be replaced as necessary. The District Director of Clinical Services or designee will re-train the Health and Wellness Director and the Health and Wellness Coordinators on First Aid Kit contents and maintenance. 3. Responsible Party: Health and Wellness Director 4. The Health and Wellness Director and/or designee will complete monthly audits to verify all First Aid Kits are appropriately stocked and expiration dates are noted. 5. Completion date: December 31, 2021 and on-going.
22VAC40-73-650-A
Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedures, 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 for five of five sampled records.
Evidence
  1. Resident #1’s August and September 2021 medication administration record (mar)documented the following medications were administered and started, changed, or discontinued without signed physician or prescriber’s order: (a) Mobic 7.5 mg discontinued 8-10-21, (b) Norco 7.5-325 mg, twice a day discontinued 9-10-21, the resident’s progress note dated 9-10-21 at 22:14 also documented discontinued medication, (c) Norco 7.5-325 mg prn every 24 hours, started 7-15-21, (d) Norco 7.5-325mg every 6 hours, started 8-17-21 and discontinued 8-24-21, (e) PreserVision AREDs started 7-15-21; (f) Zofran 4mg prn, started 5-27-21.
  2. Resident #2’s documentation of sixteen medications on August 2021 MAR and thirteen medications documented on September 2021 MAR, physician’s orders not received per inspection request for documents on 9-16-21 and 9-30-21.
  3. Resident #3’s August 2021 did not include signed physician’s orders for the following: (a) Vitamin D, (b) Cozaar, (c) Melatonin, (d) Dexamethasone, (e) Thera Tab multivitamin, and (f) Cephalexin Suspension.
  4. Resident #4’s August 2021 MAR did not include signed physician’s orders for the following: (a) Fidaxomicin start date 8-19-21 and discontinued 8-23-21, (b) Flagyl 500mg start date 8-23-21 and (c) Potassium Chloride discontinued 8-3-21.
  5. Resident #5’s August 2021 MAR did not include signed physician’s orders for the following: (a) Buspirone (b) Spironolactone and (c) Restasis 0.05% discontinued 8-3-21.
  6. On 9-30-21 and 10-7-21 during exit meeting, physician’s or prescriber’s orders not being available were addressed with staff #1 and #2.
Plan of correction
1. For Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 signed physician/prescribers orders were obtained for the medications that were administered and started, changed, or discontinued. 2. Resident records will be audited for valid signed physician/prescribers orders for medications, dietary supplements, diet, and 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. The Health and Wellness Director or designee will audit 10% of resident physician orders monthly for completeness and healthcare provider signatures. 5. Completion date: December 31, 2021 and ongoing.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to ensure it report to the licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety or welfare of any resident.
Evidence
  1. Resident #3’s Progress Notes, dated 8-27-21 at 14:30 documented resident readmitted from a local hospital with new medication orders, a catheter and 2 liter nasal cannula. An incident report was not sent to the licensing office.
  2. Resident #4’s Progress Notes, dated 6-1-21 out to emergency room and 6-8-21 documented resident’s return from hospital. Resident out to hospital on 6-22-21 and returned from hospital on 6-28-21 with “contact precautions in place due to C-Diff”.
  3. On 9-30-21 and 10-7-21 during the exit, incident reporting was addressed with staff #1 and #2.
Plan of correction
1. Resident # 3 and #4 were sent out for change in condition, no incident had occurred. 2. Incident reports will be audited to ensure a report of a major event that had negatively affected or threatened the life, health, safety or welfare of a resident was reported to the licensing office per state regulation. Associates will be re-educated on state requirement of reporting a major incident that negatively affects or threatens the life, health, safety, or welfare of a resident. 3. Health and Wellness Director and Executive Director or designee will continue to monitor and report major events that negatively affects or threatens the life, health, safety or welfare of a resident. 4. Responsible party: Health and Wellness Director and Executive Director 5. Completion: December 31, 2021 and on-going
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents including over-the-counter medications and dietary supplements include all regulatory requirements for three of five sampled records.
Evidence
  1. Resident #1’s August 2021 and September medication administration record (MAR) was blank/did not include the initials of the direct care staff administering the following medications: (a) Levothyroxine and (b) Prilosec on 8-3-21, 8-14-21-and 8-15-21 and 9-8-21 and (c) Norco 5-325mg-(prescribed three times a day)-on 9-13, 9-14, and 9-15-21.
  2. Resident #3’s August 2021 MAR was blank/did not include the initials of the direct care staff administering the following: (a) Aspirin, CoQ10, Cozaar, Omeprazole, Thera multivitamin and Namenda on 8-5-21 and (b) Aricept, Remeron, Pravastatin and Namenda on 8-14-21.
  3. Resident #4’s August 2021 MAR was blank/did not include the initials of the direct care staff administering the following: (a) Lantus Solostar on 8-6-21 and (b) Humalog on 8-15-21.
  4. On 9-30-21 during exit, MARS were addressed with staff #1 and #2.
Plan of correction
1. Resident #1 PCP and responsible party will be informed of missed medication administration on 8/3/21, 8/14/21, 8/15/21 9/8/21, 9/13/21, 9/14/21, and 9/15/21. Resident #3 PCP and responsible party of missed medication administration on 8/5/21 and 8/14/21. Resident #4 PCP and responsible party were informed of missed medication administration on 8/6/21 and 8/15/21. 2. Resident MARs will be audited for missed documentation of medication administration. The clinical staff will be re-educated on medication administration and documentation. 3. The Health and Wellness Director or designee will audit 10% of resident MAR (Medication administration record) monthly for documentation compliance. 4. Responsible party: Health and Wellness Director. 5. Completion date: December 31, 2021 and ongoing
March 10, 2021Inspection2 violations
Inspection dates
March 10, 2021 , March 11, 2021 , March 17, 2021 and April 14, 2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 3-11-21 and concluded on 4-14-21. A self-reported incident was received by the department regarding allegations in the resident care and related areas of standard. The assistant executive director was contacted by telephone to conduct the investigation. The licensing inspector emailed the assistant executive director a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report allegation of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for a resident.
Evidence
  1. On 3-12-21, resident #1’s physical examination dated 2-9-21 submitted for review, documented resident’s need for skilled nursing to be evaluated and treated.
  2. Further review of resident #1’s progress notes (nurse’s notes) documented on 2-16-21, both legs of resident was wrapped by home health nurse.
  3. A review of the resident’s individualized service plan (ISP) dated 2-20-21 did not document skilled nurse nursing need.
  4. On 4-14-21, staff #1 provided documentation of home health providing skilled nursing services to resident #1 following resident’s 2-16-21 admission. However, this assessed need was not documented on the resident's ISP.
  5. The submitted Fall Rating document for resident #1 did not include the date nor the signature of the assessor. This assessed need was not documented on the resident's ISP.
  6. On 4-14-21, staff #1 acknowledged resident #1’s skilled nursing service and fall risk assessed needs were not documented on resident’s ISP.
Plan of correction
The following is the Plan of Correction for Brookdale Chambrel Williamsburg regarding the Statement of Deficiencies dated April 14, 2021. 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. 22VAC40-73-(6)-450-C 1. The ISP for Resident #1 was updated on 4/26/2021 to reflect skilled nursing service and fall risk assessed needs on the ISP. 2. The Health and Wellness Director will audit the ISP’s of Resident records to acknowledge that the residents assessed needs of skilled nursing services and fall risk assessment are documented on the ISP. ISP’s will be updated accordingly. The Health and Wellness Director will be re-educated on ISP documentation by the District Director of Clinical Services by May 15, 2021. 3. Responsible Party: The Health and Wellness Director 4 The Health and Wellness Director and/or designee will audit 10% of resident ISP’s monthly to acknowledge skilled 4. The Health and Wellness Director and/or designee, will audit 10% of resident ISP’s monthly to acknowledge skilled nursing services and fall risk assessed needs are documented onto the ISP’s. This report will be brought to the Quality Assurance meeting and be reviewed at the Healthcare Oversight assessment. 5. Completion date: May 15, 2021 and on-going
22VAC40-73-470-A
Based on record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met.
Evidence
  1. On 3-12-21, resident #1’s physical examination dated 2-9-21 review, documented resident’s need for physical therapy and occupational therapy to be evaluated and treated.
  2. Further review of resident’s individualized service plan dated 2-20-21 did not document service needs. A review of resident’s progress notes (nurse’s notes) submitted did not document therapy services.
  3. On 4-14-21, staff #1 acknowledged, resident #1’s physical examination included orders for therapy services. Staff also acknowledged, the facility did not provide services nor did the facility assist the resident or family in making arrangements for the recommended health care services.
Plan of correction
1. Resident #1 was referred for skilled nursing and had already met her therapy goals. Her ISP has been updated to reflect skilled nursing needs on 4/26/2021. The physician and POA were informed she had already met her therapy goals during a previous referral which ended prior to admission to assisted living. 2. The Health and Wellness Director will audit the physician orders of Resident records to acknowledge that the residents assessed needs of therapy services are documented on the ISP and orders are followed through with the evaluation and treatment of therapy. ISP’s will be updated accordingly. The Health and Wellness Director will be re-educated on ISP documentation and follow through on physician orders for evaluation and treatment of therapy by the District Director of Clinical Services by May 15, 2021. 3. Responsible Party: The Health and Wellness Director 4. The Health and Wellness Director and/or designee, will audit 10% of resident ISP’s and physician orders monthly to acknowledge documentation on the ISP for therapy needs and follow through on physician orders for therapy. This report will be brought to the Quality Assurance meeting and be reviewed at the Healthcare Oversight assessment. 5. Completion date: May 15, 2021 and on-going
November 2, 2020Complaint survey3 violations
Inspection dates
Nov. 2, 2020 , Nov. 9, 2020 , Nov. 13, 2020 and Dec. 22, 2020
Areas reviewed
22VAC40-73 (2)- ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 (4)- STAFFING AND SUPERVISION22VAC40-73 (5)- ADMISSION RETENTION AND DISCHARGE22VAC40-73 (6)- RESIDENT CARE AND RELATED SERVICES22VAC40-73 (10) Additional requirements for serious cognitive impairments
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 11-2-20 and concluded on 12-22-20. A complaint was received by the department regarding allegations in the areas of resident care and related services, administration and administrative services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the assistant executive director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-40-A
Based on record review and staff interview, the facility failed to ensure it complied with the facility’s own policies and procedures related to its resident agreement for a resident.
Evidence
  1. During the complaint inspection regarding notification of resident’s rate increase for services, the facility was not able to provide documentation of the aforementioned increase for resident #1. 2.A review of resident #1’s residency agreement dated 1-15-20, noted, on page 2, Section I- Services and Accommodations; section B- Personal Service Plan, noted, ??.periodically throughout your residency, we will use a personal service assessment to determine the personal services you require. The personal assessment will be used to develop your Personal Service Plan. The results of the assessment and the cost or providing the additional personal services (the Personal Service Rate) will be shared with you“..” 3.Further review of the resident agreement, on page 6, Part III- Rates, section F- Rate Changes, noted??We will provide thirty (30) written notice of any change in rates or pricing for Basic Services, Personal Services, Select Services and Therapeutic Services. We may offer or require a change in Personal Service Plan when we determine additional services are requested or required. The new Personal Service Plan Rate resulting from a change in your Personal Service Plan is effective immediately after written notice is given.? 4.Interview with staff #3 and #4, neither individuals could provide documentation of notification of rate increase for services to the resident/or legal representative
Plan of correction
The following is the Plan of Correction for Brookdale Chambrel Williamsburg regarding the Statement of Deficiencies dated December 23, 2020. 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. 22VAC40-73-(2)-40A Resident #1 is has been discharged. The AL Director will audit resident personal service rate agreements for appropriate signatures acknowledging receipt of rate change. Personal service rate agreements needing signatures acknowledging notice of rate changes will result in arranging a family meeting to discuss care with the Health and Wellness Director and rate increase with the AL director. The AL Directors will be re-educated on obtaining acknowledging signatures on the personal service rate changes documentation per state regulation and Brookdale policy. Responsible party: AL Director AL Director or designee will audit 20% of resident personal service rate agreements monthly to verify written notice has been provided to the resident or his legal representative of any change in personal service plan rates per state regulations and Brookdale policy. This will be brought to the Quality Assurance meeting. Completion date: February 1, 2021 and on-going
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. During the complaint inspection, a review of resident #1’s individualized service plan (ISP) updated 6-18-20 by the developer, did not include all assessed needs for resident #1. The resident’s initial assessment for placement in the facility’s safe, secure unit (scu) dated 1-14-20 noted resident to have ?poor judgement, difficulty concentrating, poor memory, very little if any abstract reasoning, limited thought process, and occasional agitation. However, the ISP did not address resident’s assessment. 2.A review of page #7 of resident #1’s ISP noted ?8-18-20- resident agitated with redirection, take for walks outside, call daughter to speak with him, and PL associates to take on daily walks“. Notation dated 9-11-20, ”resident found with another resident in his own room, PL in place“ one-on-one ”24/7?. Another notation dated 10-1-20, resident has one-on- one, sitters with a local agency. Staff #3 and #4 acknowledged notations on ISP were concerns that were noted on the ISP but were not documented with all required components per regulations for an ISP.
Plan of correction
Resident #1 has been discharged. The Health and Wellness Director will audit resident Individualized Service Plans to verify assessed needs are included. The Health and Wellness will update individualized service plans as necessary per state regulations and Brookdale policy. The clinical staff will be re-educated on creating and updating the Individualized Service Plan per state regulation and Brookdale policy. Responsible party: Health and Wellness Director The Health and Wellness Director or designee will audit 10% of resident Individualized Service Plans monthly to verify assessed needs are included and discussed with the legal representative per state regulations and Brookdale policy. This will be brought to the Quality Assurance meeting. Completion date: February 1, 2021 and on-going
22VAC40-73-450-E
Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or his designee, the person who developed the plan, and by the resident or his legal representative.
Evidence
  1. During the complaint inspection, a review of resident #1’s individualized service plan (ISP) dated 1-23-20 and signed by the developer did not include the signature of the resident or the legal representative.
Plan of correction
Resident #1 is has been discharged. The Health and Wellness Director will audit resident individualized service plans for appropriate signatures and dates by the licensed administrator or his designee, by the developer, and the legal representative acknowledging a review of the individualized service plan has been reviewed. Individualized Service Plans needing signatures will result in arranging a family meeting to discuss care with the Health and Wellness Director. The AL Directors and Health and Wellness Directors will be re-educated on obtaining signatures on the Individualized Service Plan per state regulation and Brookdale policy. Responsible party: Health and Wellness Director Health and Wellness Director or designee will audit 20% of resident Individualized Service Plans monthly to verify it has been reviewed with the resident or his legal representative and signed by the developer, the licensed administrator or designee, and the legal representative state regulations and Brookdale policy. This will be brought to the Quality Assurance meeting. Completion date: February 1, 2021 and on-going