VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Arbor of Williamsburg
935 Capitol Landing Drive
Williamsburg, VA 23185
(757) 565-3583

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Feb. 6, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 63.2 GENERAL PROVISIONS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

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: 2/6/2023 8:00am- 7:00pm 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: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 5 Observations by licensing inspector: Licensing Inspectors observed medication passes, audit medication carts, observed breakfast, reviewed staff and resident records as well as mandatory oversight reports. Additional Comments/Discussion: Technical assistance was provided in several areas. 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 Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility railed to ensure the physical examination included all requirements. Evidence: 1. Resident # 7`s physical examination dated 12/2/2022 did not include the resident?s height and date of physical examination. 2. Staff # 1 acknowledged the resident?s physical examination did not include all required information.
Plan of Correction:	All resident physical examination and report documents will be audited by the community?s Resident Care Director to ensure all information is documented as required. Going forward: The Resident Care Director and Executive Director will review all Physical Examination and Report documents prior to the resident?s move in. Any corrections needing to be made will be requested prior to the resident?s move in date.
Standard #:	22VAC40-73-325-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. Evidence: 1. Resident # 9?s record included documentation of falls on 1/9/2023 and 1/31/23. The most recent fall assessment was 12/26/22. 2. Resident # 1`s record included documentation of falls on 8/26/22, 9/6/22, 10/15/22, 11/28/22, 12/25/22, 1/8/23, and 1/26/23. The only documented fall risk assessment for the resident was dated 2/6/23. 3. Staff members #1 and #3 acknowledged there were no other fall risk assessments for the above residents.
Plan of Correction:	Resident #9 and Resident #1 have had fall risk assessments completed for each fall. Community?s Resident Care Director will audit for any missing fall risk assessments and update accordingly. Going forward: The Resident Care Director, Cottage Care Coordinator or Assistant Resident Care Coordinator will complete a Fall Risk assessment after each fall.
Standard #:	22VAC40-73-410-A
Description:	Based on records reviewed and staff interviewed, the facility failed to document an orientation was provided to a new resident and their legal representative which included emergency response procedures, mealtimes, and use of the call system. Evidence: 1. The record for Resident #2 did not include documentation the resident received the required orientation. 2. Staff # 1 and Staff # 3 acknowledged the resident?s record did not contain documentation the resident was provided orientation.
Plan of Correction:	An audit will be completed by the Resident Care Director and Executive Director of all resident files to ensure orientation documentation was completed at time of move in. If documentation is not included in the resident file, orientation will be provided to the resident and the appropriate documentation will be completed at that time. Going forward: The Executive Director will ensure each resident is provided orientation at move in and the required documentation is completed.
Standard #:	22VAC40-73-440-B
Description:	Based on records reviewed and staff interviewed the facility failed to ensure that for private pay individuals, the UAI shall be completed by an assisted living facility staff who has successfully completed state-approved training and the form shall be signed by the administrator or the administrator?s designee. Evidence: 1. Resident # 2?s UAI with an assessment date of 1/17/23 did not contain a signature of the administrator or administrator?s designee. 2. Resident #4?s UAI with an assessment date of 2/2/23 did not contain a signature of the administrator or administrator?s designee. 3. Resident #1?s UAI with an assessment date of 6/27/22 did not contain a signature of the administrator or administrator?s designee. 4. Staff #3 acknowledged the aforementioned UAIs did not contain the required signatures.
Plan of Correction:	Resident #2 and Resident #4 UAIs have been reviewed by the Administrator and each has been signed. An audit of the Resident charts will be completed to ensure the appropriate signatures are on all UAIs. If the signature is not present, the Administrator will sign at that time. Going forward: The Resident Care Director, Assistant Resident Care Coordinator or the Cottage Care Coordinator will present the completed UAI to the Administrator for signature immediately following completion of the UAI.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record reviewed, the facility failed to have the ISP (Individualized Service Plan) signed by the resident or his/her legal representative. Evidence: Resident #1?s ISP dated 4/30/22 did not contain a resident or legal representative signature.
Plan of Correction:	The community?s Resident Care Director will audit all resident ISPs to ensure each have been reviewed by responsible party. If the responsible party is unavailable to sign ISP immediately, documentation will be made referring to notification of responsible party. Going forward: The Resident Care Director, Assistant Resident Care Coordinator or Cottage Care Coordinator will review completed ISPs in person with the responsible parties. If the Responsible Party is not available in person to review the ISP, a review will be completed over the phone and the ISP will be sent to RP for signature. Every attempt made to receive a signature will be documented appropriately and followed up on.
Standard #:	22VAC40-73-700-2
Description:	Based on observation and staff interviewed, the facility failed to ensure when oxygen therapy is provided, it met and maintained the required safety precaution. Evidence: 1. On 2/6/23 during a tour of the safe, secure unit, oxygen tank and other oxygen supplies were observed in use by Resident #1. The ?No Smoking-Oxygen in Use? sign was not posted on the door or in the room. 2. Staff #3 and Staff # 6 acknowledged the resident received oxygen and the ?No-Smoking Oxygen in Use? sign was not posted.
Plan of Correction:	Resident #1 has `No smoking, oxygen in use? sign posted at doorway. All residents using oxygen will have `No smoking, oxygen in use? sign posted in plain sight. Going forward: The Resident Care Director will in-service the resident care team to the requirement of the ?No Smoking, Oxygen in Use? sign for all resident?s requiring oxygen.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure Do Not Resuscitate (DNR) order was included on the Individualized Service Plan (ISP). Evidence: Resident #2?s ISP dated 1/17/23 states the resident is a full code, however the resident has a DNR in the file dated 6/28/22.
Plan of Correction:	The community?s Resident Care Director will audit each resident?s ISP to ensure all DNR orders are documented as required. Going forward: All ISP?s will be updated by the Resident Care Director and Cottage Care Coordinator to note code status as appropriate.
Standard #:	22VAC40-73-970-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure fire drills were conducted in accordance with the current edition of the Virginia Statewide Fire Prevention Code and that drills required for each shift in a quarter were not conducted in the same month. Evidence: 1. A review of the of the fire and safety drill log sheet indicated fire drills were conducted as follows: No drill was documented in July 2022 August 2022 drill was conducted on the 1st shift No drill was documented in September 2022 There was no documentation of a drill occurring on the 2nd or 3rd shifts in the third quarter of 2022. 2. Staff # 5 and Staff # 1acknowledged fire and safety drills were not conducted in accordance with the Virginia Statewide Fire Prevention Code.
Plan of Correction:	The community?s Maintenance Director will conduct a Fire and Safety drill for each shift in the month of February. Going forward: The Maintenance Director will conduct monthly Fire and Safety Drills, rotating shifts each month.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kits contained all required items. Evidence: 1. On 2/6/23, during a check of the facility?s first aid kit on the safe, secure unit with Staff #3, the first aid kit did not include a disposable single use breathing barrier or shields for use with rescue breathing or CPR mask or other type. 2. The first aid kit for the van used to transport residents was checked with Staff # 5. The first aid kit did not include antiseptic wipes or ointment, disposable breathing single use breathing barrier or CPR mask, hand sanitizer (expired 5/2/22), plastic bags, scissors, flashlight and extra batteries, thermometer, triangular bandages and tweezers. 3. Staff # 3 and Staff # 5 acknowledged the first aid kits did not contain all the required items.
Plan of Correction:	All community First Aid Kits have been stocked with all required items. Going forward: All First Aid Kits will be checked monthly and restocked by the Resident Care Department.