VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Chambrel Williamsburg
3800 TREYBURN DRIVE
Williamsburg, VA 23185
(757) 220-1839

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: May 2, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 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:

Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	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.