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. 4, 2020 , Nov. 6, 2020 , Nov. 9, 2020 , Nov. 11, 2020 and Nov. 12, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on November 4, 2020 and concluded on November 12, 2020. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services and resident behaviors. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. Consultation provided on staff training hour requirements, special care staff training hour requirements, ensuring all medications have diagnoses listed on physician?s orders, and medication administration documentation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The complaint is valid.

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure prior to his admission to a safe, secure environment, the resident was assessed by an independent physician as having an inability to recognize danger or protect his own safety and welfare, and that the assessment included behavior/psychomotor; speech/language; and appearance. Evidence: 1. Resident #1 admitted to the safe, secure environment (SSE) on 07-16-20. The resident?s ?Assessment of Serious Cognitive Impairment? dated 07-15-20 was checked ?no? for ?Is the individual named above unable to recognize danger or protect his/her own safety and welfare?? 2. Resident #1?s ?Assessment of Serious Cognitive Impairment? was blank in the areas of behavior/psychomotor, speech/language, and appearance. 3. Staff #1 confirmed that resident #1 resides in the SSE and that the resident?s assessment did not document an inability to recognize danger or protect his own safety and welfare, and that areas on the form were left incomplete.
Plan of Correction:	The Assessment of Serious Cognitive Impairment was sent to the physician to be completed. Assistant Wellness Director will ensure that all areas of the form is complete and that "no" is not checked for the question "is the individual named above unable to recognize danger or protect his/her own safety and welfare?" Assistant Wellness Dir. and Wellness Director will do an audit of other Assessment of Serious Cognitive Impairment forms of residents in our memory care to ensure they're filled out completely and accurate. Executive Director will review forms after each admissions.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change of a resident?s condition. Evidence: 1. Resident #1?s ISP dated 07-16-20 did not document aggressive behaviors and agitation; however, nursing notes document incidents of agitation and aggressive behaviors occurring on 09-04-20, 09-09-20, 10-03-20, 10-09-20, and 10-23-20. 2. Resident #1?s ISP dated 07-16-20 documented resident has no allergies; however, resident?s physical examination dated 07-15-20 documented resident has allergies to peanuts, corn, and bell peppers.? Additionally, Nurses Notes dated 09-03-20 documented resident #1 has an allergy to Lisinopril. 3. Resident #2?s ISP dated 01-16-20 did not document agitation, aggressive behaviors, or combativeness. Nursing notes documented incidents of agitation, combativeness, and aggression towards residents/staff occurring on 07-23-20, 10-18-20, 10-21-20 ? 10-25-20, 10-27-20, 11-02-20, and 11-04-20. 4. Staff #1 confirmed during discussion that resident #1 and resident #2 both displayed aggressive behaviors that were not documented on ISPs, and resident #1's allergies were not documented on the ISP.
Plan of Correction:	Resident #1 and Resident #2 ISP will be updated and be reflective of the resident, behaviors and allergies. Assistant Wellness Dir and Wellness Director will audit memory care ISPs to ensure that ISPs capture behaviors and allergies (if any). Wellness Director and Executive Director will conduct random audits to ensure that all ISPs are current and reflective of each resident's current condition.
Standard #:	22VAC40-73-480-C
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to arrange specialized rehabilitative services by qualified personnel as needed by the resident, including physical therapy (PT), occupational therapy (OT), and speech-language pathology services (ST). Evidence: 1. Resident #1 received orders dated 07-20-20 for ?OT/PT/ST Evaluate/Treat?. The OT/PT Treatment Plan documented the following: ?Therapeutic Exercise, Neuromuscular Re-education, Orthotics/Prostheses, Gait Training, Wheelchair Management, Cognitive Skills Development, Therapeutic Activities, Self-Care/Home Management, Modalities as Indicated, Moist Heat/Ice, Electrical Stimulation/Ultra Sound, Contrast Bath/Paraffin, Manual Therapy, Community ReIntegration, Patient/Caregiver Education & Discharge Planning.? 2. Staff #1 confirmed services for resident #1 did not start for the resident as of the date of the inspection.
Plan of Correction:	Order for Physical Therapy, Occupational Therapy, and Speech Therapy was discontinued on 11/16/20. Wellness Director will train RMAs on chart checks to ensure orders are followed through. Assistant Wellness Director and Wellness Director will review all new orders daily.
Standard #:	22VAC40-73-550-D
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to establish written policies and procedures for implementing ? 63.2-1808 of the Code of Virginia. Evidence: 1. The facility?s policy on resident rights was requested during the inspection. 2. Staff #1 could not produce the resident rights policy during inspection.
Plan of Correction:	Resident Rights policy was received from HR and Resident Rights were reviewed at staff meeting on 11-20-20.