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 23, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 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: 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:

Standard #:	22VAC40-73-450-C
Description:	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.