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: Oct. 25, 2021

Complaint Related: No

Areas Reviewed:

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

Comments:

A renewal inspection was initiated on 10/25/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, and additional facility documentation to ensure compliance. The inspector conducted the on-site portion of the inspection on 10/25/21. An exit interview with the Administrator was completed. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations cited during the inspection are contained within this violation summary.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure the comprehensive serve plan (1)included description of identified need; (5) date outcome achieved. Evidence 1: While reviewing resident record #1's Individualized Service Plan dated 07-19-2021, did not address the residents need for Catheter care as addressed by the residents recent Uniform Assessment Instrument nor the Physician Order sheet dated 04-23-2020. Evidence 2: While reviewing resident #2's Individualized Service Plan dated 04-09-2021, the Licensing Inspector observed that resident #2's Individualized Service plan did not have any dates for outcome achieved. Evidence #3: While reviewing resident #3's Individualized Service Plan dated 07-22-2021, resident #3's Individualized Service Plan did not address the residents orientation-" disoriented all spheres, some of the time" as noted on resident #3's Uniform Assessment Instrument dated.
Plan of Correction:	1. Items were discontinued from the resident?s chart since there is no longer a foley in place. 2. A 100% audit will be done by the WD, AWD, or designee to ensure that all residents that have catheters have the correct documentation. The audit will be completed by January 21, 2022. 3. A 100% audit will be completed by the WD, AWD, or designee on all resident ISP to ensure that all have the outcome achieved dates documented. The audit will be completed by January 21, 2022. 4. A 100% audit will be completed on all residents ISP by the WD, AWD, or designee to ensure that all residents orientation is documented. The audit will be completed by January 21, 2022. This will be audited quarterly to ensure compliance. 5. An in-service will be completed by the WD or AWD educating the Medication aids on timely notification of any changes in regards to the residents, so that it can be documented on the residents ISP. The in-service will be completed by January 21, 2022.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review the facility failed to ensure the Individualized Service Plan was signed by the resident or his legal representative. Evidence: While reviewing resident record #3, the individualized service plan dated 07/22/2021 was not signed by resident #3's responsible party.
Plan of Correction:	1. A 100% audit will be completed on all residents ISP by the WD, AWD, or designee to ensure that all ISPs are signed. Resident?s or their POAs will be contacted to have ISP reviewed and signed. The audit will be completed by January 21, 2022. 2. The WD or Assistant Wellness Director will do monthly audits to ensure that the ISPs stay within compliance. 3. An in-service will be completed by the WD with the AWD to review the auditing process and notification of POAs for ISP signatures.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation of the facility physical plant the facility failed to ensure the storage the storage area was locked. Evidence: While observing resident #3's room, Licensing Inspectors observed an unlocked cabinet containing skin wound care cleaner as evidenced by photo taken.
Plan of Correction:	1. All items were removed from the resident?s room and secured in a safe area away from the residents. 2. The cabinets in the resident?s rooms will be checked at the beginning of each shift to ensure that they are locked and secure. 3. A signature confirmation will be added to the EMAR for each shift to confirm that the cabinets were checked 4. WD, AWD, or designee will do daily rounds to ensure the unit is in compliance with the POC. 5. An in-service will be completed by WD or Assistant Wellness Director with all CNAs and RMAs on proper protocol to ensure all hazardous items are locked away from residents by January 21, 2022.