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: Feb. 13, 2020 and Feb. 14, 2020

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was completed by the Licensing Inspector on February 13, 2020 from 9:45 am until 5:26 pm and on February 14, 2020 from 9:40 am until 4:17 pm. There were 73 residents in care. The Executive Director and Director of Nursing were present. During the inspection a tour of the building was conducted. A medication observation was conducted and medication carts were reviewed in the assisted living unit and in the memory care unit. Resident records and staff records were reviewed. A review of criminal background checks was conducted for all new staff hired since the last annual inspection. Lunch was served as posted on the menu. The following was discussed with the Executive Director and Director of Nursing: staff availability in the assisted living dining room, staffing patterns, ISP outcome achieved dates, and the approvals for residents admitting to the safe, secure environment (memory care unit). Also discussed reviewing all admission documentation to ensure completeness and accuracy, to include the physical examination report and admission orders.The areas of non-compliance were discussed throughout the inspection and during the exit meeting. 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 with the standard(s) 2. Measures to prevent re-occurrence, and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action(s). The plan of correction is due within 10 calendar days.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the physical examination report contained all of the required information. Evidence: 1. Resident #8's physical examination report dated 3-28-19 was missing the resident's telephone number, height, weight, pulse, blood pressure, and allergy information. The medical history section was left blank and the question regarding the resident's need for "continuous licensed nursing care" was not answered. 2. Resident #9's physical examination was missing the date of the physical exam. 2. Staff #1 and staff #2 acknowledged resident #8 and resident #9's physical examinations were missing the required information.
Plan of Correction:	Steps to correct the non-compliance with the standards: Resident #8?s height, weight, pulse and blood pressure was obtained on 4/18/19 by staff upon admission. Resident #9?s physician dated his history and physical form in multiple places on the form. Measures to prevent the non-compliance from happening again: All new admission physical examination will be completed and documented upon admission. All new admission reports will be reviewed for completion of physical information prior to admission. Wellness Director and /or designee will audit admission forms for completeness. Audits will be submitted to Quality Assurance Committee for three months to ensure admission form are completed prior to admission.. Person(s) responsible for implementing each step and/or monitoring any preventative measures: Wellness Director and/or designee
Standard #:	22VAC40-73-450-C
Description:	Based on observation, record review, and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) contained a description of the resident's identified needs. Evidence: 1. On 2-13-2020 resident #2 was observed to have a strong foul odor. Staff #3 stated the odor was coming from the resident's left hand which was observed to be contracted. Staff #3 stated staff clean the resident's hand daily to prevent an odor. 2. Resident #2's ISP dated 12-26-19 did not reflect the resident's need for assistance with cleaning, washing, and ensuring the left hand was maintained odor free.
Plan of Correction:	Steps to correct the non-compliance with the standards: Resident #2?s left hand is being cleaned daily with a cleansing product. Residents ISP was updated on 2/14/20 to reflect the need for assistance with hand washing. Resident has a follow up medical appointment on 3/10/2020 for further evaluation of the contracted hand. Measures to prevent the non-compliance from happening again: All residents with contractures will be evaluated by therapy and staff trained on specific individualize care for meeting such needs.. Individual needs will be recorded on ISP. Person(s) responsible for implementing each step and/or monitoring any preventative measures: Wellness Director or designee
Standard #:	22VAC40-73-460-H
Description:	Based on observation, record review, and interview, the facility failed to ensure that personal assistance was provided to each resident as necessary, including assistance with toileting. Evidence: 1. On 2-13-2020 during the medication administration observation at approximately 1:00 pm, resident #2 requested assistance with toileting. Staff #3 accompanied the resident into the bathroom and exited approximately two minutes later. Staff #3 exited the resident's room while the resident remained in the bathroom. Staff #3 returned to the medication cart and proceeded to administer medications to a different resident. Staff #3 did not return to resident #2's room to provide assistance. 2. Staff #3 stated that resident #2 is able to complete toileting tasks without physical assistance. However, resident #2's Uniform Assessment Instrument dated 12-26-19 documented the resident needed mechanical and human help/physical assistance with toileting. The Individualized Service Plan dated 12-26-19 documented resident needs "physical assistance to dress/undress, toilet, and perform peri care". 3. During interview, staff #3 acknowledged resident #2 was left unattended in the bathroom.
Plan of Correction:	Steps to correct the non-compliance with the standards: Resident #2?s ISP was updated on 2/14/2020 to reflect her desire to self-manage toileting when capable.Measures to prevent the non-compliance from happening again: Resident activities of daily living (ADL) form will be reviewed to ensure accurate reflection of ADL?s for toileting is noted on resident ISP. ADL forms will be audited monthly by the Wellness Director or designee to ensure accuracy. Audits will be completed for 3 months and submitted to the communities Quality Assurance Committee. Person(s) responsible for implementing each step and/or monitoring any preventative measures: Wellness Director and/or designee
Standard #:	22VAC40-73-550-G
Description:	Based on record review and interview, the facility failed to ensure the rights and responsibilities of residents were reviewed annually with each staff person, with written acknowledgement as evidence of the review. Evidence: 1. Staff #3 and staff #5 did not have evidence of an annual review of the rights and responsibilities of residents. Staff #9 and staff #10 were unable to provide documentation of the most current review of resident's rights for staff #3 and staff #5. 2. Staff #10 acknowledged there was no documentation of an annual review of resident rights for staff #3 and #5.
Plan of Correction:	Steps to correct the non-compliance with the standards: Staff # 3 and staff #5 annual review of resident rights was completed on 2/18/20. Measures to prevent the non-compliance from happening again: A complete audit of all staff training on resident rights was completed on 2/18/2020. Monthly audits will be completed for 3 monthly and submitted to the Quality Assurance Committee. Person(s) responsible for implementing each step and/or monitoring any preventative measures: Executive Director and/or Activity Director
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure verbal orders were reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. Resident #1 had a verbal order dated 9-13-19 for a change in Duloxetine from 60mg to 30mg. The order was not signed by a physician or other prescriber as of 2-13-2020. 2. Resident #3 had a verbal order dated 12-2-19 to discontinue Vitamin D3, Vitamin B12, and to discontinue labs ordered on 11-26-19. The order was not signed within 14 days. 2. Staff #2 acknowledged the orders were not signed by a physician within 14 days.
Plan of Correction:	Steps to correct the non-compliance with the standards: Resident #1?s verbal order was signed by the physician on 2/13/20. Resident #3 did not have orders for Vitamin D3, Vitamin B12 or labs. Resident #4 had a verbal order to discontinue Vitamin D3, Vitamin B12 and labs which was signed on 2/21/20. Measures to prevent the non-compliance from happening again: Verbal orders will be placed in the physician communication binder for signature within the 14 day period. A copy of all Verbal orders will be given to the Wellness Director and/or designee to ensure signatures are obtained within the 14 day period. Random audit of verbal orders will be conducted for 4 months to ensure compliance. Audits will be submitted to the Quality Assurance Committee. Person(s) responsible for implementing each step and/or monitoring any preventative measures: Wellness Director and/or designee
Standard #:	22VAC40-73-680-E
Description:	Based on observation, record review and interview, the facility failed to ensure treatments ordered by a physician or other prescriber were provided according to his instructions . Evidence: 1. On 2-13-2020 during the medication administration observation in the memory care unit, staff #3 applied Biofreeze 4% roll-on gel to resident #10's left shoulder. 2. The physician's order dated 2-6-2020 documented the Biofreeze 4% four times per day to both shoulders for arthritis pain. Resident #10 did not receive the Biofreeze gel to both shoulders per physician's instructions. 3. During interview, staff #3 acknowledged the Biofreeze was applied to resident #10's left shoulder and not administered in accordance with the physician's instructions.
Plan of Correction:	Steps to correct the non-compliance with the standards: Resident #10 Biofreeze order was changed on 2/13/2020 to reflect the resident?s current need to be applied to left shoulder only. Measures to prevent the non-compliance from happening again: All residents with order for Biofreeze have been reviewed to ensure proper application of the medication to the appropriate part of the body. Audit will be conducted for 3 months and submitted to Quality Assurance Committee. Person(s) responsible for implementing each step and/or monitoring any preventative measures: Wellness Director and/or designee
Standard #:	22VAC40-73-980-H
Description:	Based on observation and interview, the facility failed to ensure at least 48 hours of the supply of emergency drinking water was on site. Evidence: 1. On 2-14-2020 the resident census was 73 residents. The facility had 24 empty water bladders that hold 5 gallons each, for a total of 120 gallons.The facility did not have an additional supply of emergency drinking water. 2. Staff #4 acknowledged the facility did not have 48 hours of emergency drinking water supply at the time of inspection.
Plan of Correction:	Steps to correct the non-compliance with the standards The correct amount of emergency water was obtained on 2/14/20. Measures to prevent the non-compliance from happening again: The Food Service Director will audit emergency water supply monthly to ensure proper quantity is maintained for emergency use. Audits will be submitted the Quality Assurance Committee Person(s) responsible for implementing each step and/or monitoring any preventative measures: Food Service Director and/or designee