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: May 14, 2021 , May 17, 2021 and May 24, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 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 renewal inspection was initiated on May 14, 2021 and concluded on May 24, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 80. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, activities calendars, staff schedules, menus, healthcare, pharmacy, new medication system, and dietician oversight, health and fire inspections, submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record review and discussion, the facility failed to ensure that written approval was obtained by the resident, guardian or legal representative, or relative prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment [SSE]. Evidence: 1. Resident #2 admitted to the SSE on 02-22-2021. There was no written approval for placement (prior to placement or at the time of inspection) by the resident, guardian or legal representative, or relative. 2. Staff #1 confirmed during discussion that written approval was not obtained for Resident #1 to be placed in the SSE as of the dates of the inspection.
Plan of Correction:	1. On 5/28/21 a written approval for placement of resident 2 was completed and signed by the power of attorney and WD. 2. An audit will be completed by ED of all residents in memory care unit to ensure all residents have an approval for placement form completed and signed by the residents? power of attorney and the ED, WD or AWD. In the absence of the ED, the WD will ensure that the approval for placement form is completed and signed by Community and power of attorney. In the absence of both ED and WD, the AWD will ensure that the approval for placement form is signed by the resident?s POA and the Community. 3. The ED or designee will complete random audits for compliance.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review and discussion, the facility failed to ensure the licensee, administrator, or designee determined whether placement is appropriate prior to admitting a resident with a serious cognitive impairment to a safe, secure environment [SSE]. The determination and justification for the decision was not in writing and retained in the resident's file. Evidence: 1. Resident #2 admitted to the SSE on 02-22-2021. There was no documentation of the licensee, administrator, or designee determining whether the resident was appropriate to be placed in SSE (prior to placement or at the time of inspection). 2. Staff #1 confirmed during discussion that the written determination and justification for the decision for Resident #2?s placement in the SSE was not completed as of the dates of the inspection.
Plan of Correction:	1. The Community determined and documented that Resident 2 placement is appropriate. 2. An audit will be completed by ED of all residents in memory care unit to ensure all residents are appropriate to be placed in an SSE prior to placement. The Community will obtain a written determination and justification for the placement decision. 3. The ED or designee will complete random audits for compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and discussion, the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report shall contain any known allergy reactions. Evidence: 1. Resident #1?s date of admission was 06-30-2020; however, the physical examination was dated 10-24-2019. Resident #1?s report documented an allergy to Aspirin; however, the description of reaction was not listed. 2. Resident #2?s date of admission was 02-22-2021; however, the physical examination was dated 04-06-2021. 3. Resident #3?s report documented an allergy to Coumadin and Demerol; however, the description of reaction was not listed. 4. Staff #1 confirmed during discussion the physical was not completed within 30 days preceding admission for Resident #1 and Resident #2, and that Resident #1 and Resident #3?s allergy reaction was not listed on the reports.
Plan of Correction:	1. Residents? resident 1 and 3 physician?s will be contacted to determine the description of the reaction to the medications listed. 2. The Wellness Director (WD) or designee will audit 100% of resident charts to ensure that the examination dates on all History and Physical (H&P) forms are within 30 days of their admission dates. The Sales Director or designee will do the first check. The WD or Assistant Wellness Director (AWD) will do a second check of admission forms to ensure accuracy before putting in charts. Executive Director (ED) will conduct random audits of resident charts to ensure state standard compliance. 3. The WD or Assistant Wellness Director (AWD) will do a second check of admission forms to ensure accuracy before putting in charts. Executive Director (ED) will conduct random audits of resident charts to ensure state standard compliance.