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: Nov. 27, 2023 and Dec. 1, 2023

Complaint Related: No

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: 11/27/2023 and 12/01/2023 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: 69 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 residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing Inspectors observed activities, a meal, medication passes and conducted record reviews. 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 Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-290-B
Description:	Based on observations made during the tour of the building, the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place that is conspicuous to the residents and the public. Evidence: On 12/1/2023, during the second day of the inspection, the on-site person in charge was not correctly displayed on the posted manager?s board. The managers posted as IN were not in the building at the time the inspection began.
Plan of Correction:	Work Schedule and Posting The on-site supervisor listing is posted at the reception desk each day. This was corrected during survey process. Date Completed: 12/01/2023 Going forward: Resident Care Director and/or Assistant Resident Care Coordinator will ensure on-site supervisor is posted each day. Evening receptionist will clear managers from the ?manager?s board? at the end of their shift.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: 1. Resident #2 was prescribed Lexapro and the file provided to the Licensing Inspector contained a psychotropic treatment plan without a physician signature. 2. Staff #2 acknowledged the provided treatment plan did not contain the physician?s signature.
Plan of Correction:	Medication Management Plan and Reference Materials All narcotic logs have been reviewed by Resident Care Director to ensure each RMA has signed in and out for each shift. Educational in-service was provided for RMA?s for documentation of narcotic forms. Date Completed: 12/06/2023 Going forward: Resident Care Director and/or Assistant Resident Care Coordinator will review narcotic logs for appropriate documentation from shift to shift on a weekly basis to ensure consistent compliance for narcotic documentation. Regional Nurse will randomly audit narcotic logs during community visits.
Standard #:	22VAC40-73-410-A
Description:	Based on record review and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for a new resident and their legal representative. Evidence: Resident #2 was admitted on 8/24/2023 and the resident?s record contained documentation the resident or the resident?s representative received an orientation on 8/27/2023, after admission.
Plan of Correction:	Orientation and Related Information for Residents All resident records have been audited to ensure orientation has been provided to each resident and has been documented appropriately. Date Completed: 12/06/2023 Going forward: Orientation will be provided to residents by Resident Care Director or Assistant Resident Care Coordinator on the day of move in.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: A review of the Controlled Medication Count Record for the medication cart in the safe, secure unit and for the Blue hallway for the month of November 2023, showed staff failed to ensure counts of all control medications were documented from shift to shift.
Plan of Correction:	Medication Management Plan and Reference Materials All narcotic logs have been reviewed by Resident Care Director to ensure each RMA has signed in and out for each shift. Educational in-service was provided for RMA?s for documentation of narcotic forms. Date Completed: 12/06/2023 Going forward: Resident Care Director and/or Assistant Resident Care Coordinator will review narcotic logs for appropriate documentation from shift to shift on a weekly basis to ensure consistent compliance for narcotic documentation. Regional Nurse will randomly audit narcotic logs during community visits.
Standard #:	22VAC40-73-940-A
Description:	Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determine by at least an annual inspection by the appropriate fire official. Evidence: 1. The facility?s record contains an annual fire inspection completed on 02/17/2023. 2. Staff # 1 acknowledged the facility?s record of the last fire inspection completed is dated 02/17/2023.
Plan of Correction:	Fire safety: compliance with state regulations and local fire ordinances There was a delay in fire inspection related to absence of fire inspector when inspection was due. Upon hire of a fire inspector, Spring Arbor had a fire inspection completed as required by regulation on 12/13/2023. Date Completed: 12/13/2023 Going forward: Annual fire inspection notification will be placed on a calendar, Maintenance Director will confirm within one week of inspection due date that fire inspector is available and will complete inspection as scheduled.