VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Waterford at Virginia Beach
5417 Wesleyan Drive
Virginia beach, VA 23455
(757) 490-6672

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Nov. 7, 2019 , Dec. 2, 2019 and Dec. 20, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS

Comments:

This was an unannounced complaint inspection conducted by the Licensing Inspector from the Eastern Regional Office. The inspection was conducted on November 7, 2019 from 12:35 pm until 4:42 pm, December 2, 2019 from 1:45 pm until 4:53 pm, and on December 20, 2019 from 12:35 pm until 3:05 pm. There were 76 residents in care at the time of inspection. The complaint alleged concerns regarding the building and grounds, medications, and resident falls. Specifically, the complaint alleged there is mold and mildew throughout the facility, roaches were observed where the residents eat their meals and in resident rooms, prescription medications hidden in a bag by the nurses' station, staff working out of their scope of practice, and resident falls not treated appropriately. During the inspection, a tour of the building and grounds was conducted. Dining areas and resident rooms observed for mold, mildew, and roaches. Roaches were not observed during the three (3) on-site inspection dates. Some black spots observed in ceiling vents and resident rooms. The nurses' stations and medication carts were checked for bags of medications. Resident records were reviewed with a focus on falls. Residents and staff were interviewed. Staff schedules and call bell/ pendant response times were also reviewed. Based on the information obtained during this inspection, the complaint was found to be valid regarding the building and grounds. Other areas were reviewed, but were not substantiated. There was a discussion regarding the upcoming replacement of Air Conditioning units, Pest Control services, the facility's fall protocol, and call pendants response times and maintenance. The areas of non-compliance were reviewed with the Executive Director and the Director of Nursing throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction should include 1: Step(s) to correct the non-compliance 2. Measures to prevent re-occurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventive action(s).

Violations:

Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained clean and in good repair. Evidence: 1. On 11-7-2019 during a tour of the building with staff #2, the following areas were observed discolored and stained with yellow/brown color: a. The ceiling tiles in the hallway above the beauty shop, b. Three (3) of the ceiling tiles on the second floor, above the double doors had circular yellowish stains/discoloration, c. The ceiling tiles above the janitorial closet d. The ceiling above room 211 and above room 215 was discolored and cracked 2. The ceiling surrounding the vent located in the living room area of room 116 was cracked on the outside corner of the vent. The vent had black marks and spots along the inside of the vent. 3. The ceiling vent in front of room 13 in the memory care unit was discolored and appeared rusted with a brownish color along the sides of the vent. 4. The ceiling vent in the hallway across of the first floor nurses? station was had black spots in the middle of the vent and black marks along the corners of the vent. The black spots were also observed on three (3) ceiling tiles next to where the vent was located. 5. Staff #2 acknowledged the areas mentioned during the tour.
Plan of Correction:	This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission on the part of The Waterford at Virginia Beach as to the accuracy of the surveyors? findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community?s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The Community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies. 1.The following ceiling tile were cleaned or replaced: hallway above beauty salon, three (3) of the ceiling tiles on the second floor above the double doors, ceiling tiles above the janitorial closet, ceiling above room 211 and above room 215, the ceiling surrounding the vent located in the living room area of room 116, the ceiling vent in front of room 13 in the memory care, and the ceiling vent in the hallway across of the first floor nurses? station. 2.The air condition system in the areas affected was not efficient and produced excess moisture therefore the air conditioner was replaced. The Maintenance Director or designee will monitor the ceiling tiles for and ensure the are cleaned or replaced. Staff will be in-serviced on reporting discolored tiles to the Maintenance Director or designee. 3.The Executive Director and or Maintenance Director will be responsible for monitoring.