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: Sept. 14, 2022 and Sept. 27, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

Emergency food and Drinking Water Expected Outcome and Timeframes on Individualized Service Plan (ISP)

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection was initiated on 09/14/2022 from 8:05am-6:00pm and on 09/27/2022 from 8:20 am-5:45pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and an activity were observed. A medication pass observation was completed for five residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication cart, healthcare oversight, fire inspection report, and a health inspection report. Water temperatures were checked in a resident room. Call Bells for two residents were checked and staff responses were observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples) Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on record review the facility failed to ensure six months after placement of the resident in the safe, secure environment, and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. The record for Resident #1 documented an admission date in the special care unit as 10/12/21. The review of appropriateness of continued resident in special care unit form dated 08/12/22 was not completed as it did not document a yes or no for the section that ask ?is continued residence in the special care unit appropriate for the individual.? The form is dated 08/12/22 which is more than 6 months after resident #1 admission into the special care unit. 2. The record for Resident #2 documented an admission date in the special care unit as 03/30/2021. The review of appropriateness of continued resident in special care unit form is dated 05/10/21. There is no evidence of a six month review and annual review completed. 3. The record for Resident #3 documented an admission date in the special care unit as 10/12/20. The review of appropriateness of continued resident in special care unit form dated 08/22/22 was not completed as it did not document a yes or no for the section that ask ?is continued residence in the special care unit appropriate for the individual.? The form is dated 08/22/22 which is more than 6 months after resident #3 admission into the special care unit.
Plan of Correction:	1.The Community will ensure that Residents 1, 2, and 3 are reviewed for appropriateness to continue residency in a special care unit. 2. On July 6, 2022 the WD and WDS completed an audit to ensure residents in the special care unit are appropriately placed. 3.WD, AWD, or designee will monitor to ensure appropriateness to continue residency in a special care unit.
Standard #:	22VAC40-73-250-D
Description:	Based on the staff record review the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidence by the completion of the current screen form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for staff #4 (Date of Hire (DOH)-04/18/22) did not include a risk assessment documenting the absence of TB in a communicable form on or within 7 days prior to the first day of work. The TB risk assessment in the record documents a completed date of 09/20/22.
Plan of Correction:	1.Staff #4 file includes a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. 2.On September 28, 2022, the ED and BD completed an audit to ensure TB documentation. In addition, on October 13, 2022, the Wellness Director (WD) completed TB screening completed on all current staff members. 3.The BD will ensure TB screening completion on all new hires within 7 days before the first day of work and the Community will submit the result of a risk assessment, documenting the absence of TB in a communicable form as evidenced by the completion of the current screen form published by the Virginia Department of Health or a form consistent with it. In addition, the WD or designee will review all TB testing and/or screening before the new hire start to ensure compliance.
Standard #:	22VAC40-73-290-B
Description:	Based on the on-site observation the facility failed to develop and implement a procedure for posting the name of the current on site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 09/14/22 during a tour of the facility the LI did not observe a posting documenting the name of the on-site person in charge. 2. On 09/27/22 upon the Licensing Inspector (LI) arrival at the facility the LI did not observe a posting documenting the name of the on-site person in charge. 3. Staff #6 acknowledged the name of the on-site person in charge was not posted in the facility.
Plan of Correction:	1.The name of the current on-site person in charge is conspicuously placed at the front desk in view of residents and the public. 2.A clear picture frame will be posted at the front desk. In addition, name sheets will be printed daily with the name of the designated person in charge. The clinical staff will be in-serviced by who and date completed on the protocol of ensuring the correct name of the person in charge is posted after hours. 3.The receptionist or designee will ensure the correct name is posted before the end of the shift each day for the next day.
Standard #:	22VAC40-73-320-B
Description:	Based on record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident. Evidence: 1. The record for resident #2 documented a risk assessment for TB dated 04/12/21. The next risk assessment for TB was dated 09/27/22 which is more than annually from the previous risk assessment date. 2. The record for resident #3 documented a risk assessment for TB dated 10/11/20. The next risk assessment for TB was dated 09/27/22 which is more than annually from the previous risk assessment date. 3. The record for resident #4 documented a risk assessment for TB dated 05/10/21. The next risk assessment for TB was dated 09/27/22 which is more than annually from the previous risk assessment date. 4. The record for resident #6 documented a risk assessment for TB dated 06/10/21. The next risk assessment for TB was dated 09/27/22 which is more than annually from the previous risk assessment date. 5. The record for resident #4 documented a risk assessment for TB dated 02/25//21. The next risk assessment for TB was dated 09/27/22 which is more than annually from the previous risk assessment date.
Plan of Correction:	1. Resident 2, 3, and 4 records will be updated to document the risk assessment for TB. 2. On October 19, 2022, an audit was completed on current TB screening for all current residents. In addition, the month of September is designated for the completion of annual testing. 3. The WD or designee will ensure annual compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review the facility failed to ensure the ISP included a description of identified needs based upon the UAI (Uniform Assessment Instrument). Evidence: 1. The UAI for Resident # 1 dated 08/16/22 documented a need for mechanical and human help for bathing. The ISP dated 8/16/22 did not identify or address the mechanical help support to be provided for bathing. 2. The UAI for Resident #4 dated 06/29/22 documented a need for mechanical help for bathing. The ISP dated 07/19/22 did not identify or address the mechanical help support to be provided for bathing. 3. The UAI for Resident #4 dated 06/29/22 documented a need for mechanical help for dressing and toileting. The ISP dated 07/19/22 did not identify or address the mechanical help support to be provided dressing and toileting.
Plan of Correction:	1.Resident 1 and 4 Uniform Assessment Instrument (UAI) have been updated. 2.The WD, Wellness Director Specialist (WDS), or designee will audit current residents? files and ensure the UAI, and Individual Service Plan (ISP) is accurate. 3.The WD, WDS, or designee will ensure compliance.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review, the facility failed to ensure the ISP (Individualized Service Plan) shall be signed and dated by the resident or the legal guardian. Evidence: 1. The ISP for Resident #1 dated 08/16/22 did not include a signature of the resident or the legal guardian. 2. The ISP for Resident #3 dated 08/31/22 did not include a signature of the resident or the legal guardian. 3. The ISP for Resident # 2 dated 08/15/22 did not include a signature of the resident or the legal guardian. 4. The ISP for Resident #4 dated 07/19/22 did not include a signature of the resident or the legal guardian. 5. The ISP for Resident #5 dated 08/18/22 did not include a signature of the resident or legal guardian. 6. The ISP for Resident #6 dated 07/19/22 did not include a signature of the resident or the legal guardian. 7.The ISP for Resident #7 dated 07/19/22 did not include a signature of the resident or the legal guardian. 8.The ISP for Resident # 9 dated 05/03/22 did not include a signature of the resident or the legal guardian.
Plan of Correction:	1. Resident 1, 3, 2, 4, 5, 6, 7, and 9 ISP will be signed and dated by the resident or legal guardian. 2. ISPs will be signed by the resident or responsible party and WD, AWD, or designee once the review is completed. Audit to be completed by WD or designee to ensure compliance with all signatures and dates. 3. Schedule to be implemented by WD or AWD to ensure continued compliance.
Standard #:	22VAC40-73-450-F
Description:	The facility failed to ensure the ISP shall be reviewed annually and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. The record for resident #8 includes a most recent ISP dated 07/19/21.There is no evidence in record for resident #8 of an ISP being completed 12 months after the date of 07/19/21. 2. The record for resident # 8 includes physician orders dated 07/28/22 and 08/03/22 that documents a diagnosis of hospice evaluation and treatment. There is no evidence of a completion of an updated ISP to document the diagnosis of hospice evaluation and treatment for resident #8.
Plan of Correction:	1.Resident 8?s ISP is being reviewed at least once every 12 months and as needed for a significant change of condition. 2.The WD, Assistant Wellness Director (AWD), or designee will conduct an audit to ensure ISPs are completed at least once every 12 months and as needed for a significant change of condition. 3.The WD, AWD, or designee will ensure ISPs are completed at least once every 12 months and as needed for a significant change of condition.
Standard #:	22VAC40-73-620-A
Description:	Based on record review and staff interview the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. Evidence: 1. LI observed in the kitchen area of the facility a board titled ?diets? which documented no added salt and no concentrated sweets to include names of 16 residents who reside in the facility. 2. LI observed in the kitchen area a posting of the name of residents who require mechanical or pureed diets. 3. Staff #6 acknowledged the facility does not have documentation of an oversight of special diets.
Plan of Correction:	1.The Community will ensure there is oversight of at least every 6 months of special diets by a dietitian or nutritionist for each resident that requires a special diet. 2.The dietician has been retained for review of special diets. 3.The dietitian will be responsible for ensuring there is oversight at least every 6 months of special diets by a dietitian or nutritionist for each resident that requires a special diet.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked. Evidence: 1. On 09/14/22, the LI observed staff # 5 leave the medication cart unattended and unlocked from 09:12 am to 09:16 am. Staff # 5 was in a resident?s room during the above listed timeframe.
Plan of Correction:	1.Staff #5 was in-serviced on proper medication storage. 2.The WDS will in-service medication technicians/nurses to ensure medications are stored in a manner consistent with the current standards of practice and are locked in a secured storage area. 3.The WD or designee will randomly monitor medication carts to ensure proper storage and that carts are locked.
Standard #:	22VAC40-73-930-B
Description:	Based on observation and staff interview the facility failed to ensure there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. On 09/14/22, the LI pulled the call bell in the bathroom of resident # 12 at 3:07 pm. Resident #12 pushed the button on her emergency alert watch at 3:13 pm. At 3:25 pm staff # 5 arrived at the staff office. When asked by the LI, staff # 5 stated the signaling device terminates to the walkie talkie located in the staff office. Staff # 5 stated that she was in a staff meeting and did not have the walkie talkie with her during this meeting. Staff #5 acknowledged the location of where the signaling device terminates was not staffed during the time the call bell and the emergency alert was pulled and pushed.
Plan of Correction:	1.The Community will ensure a signaling device that terminates at a central location is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. 2.Staff will be in-service on expectations of timely responses to the call pendants please put who completed this in-service. Education provided during new hire orientation by WD, AWD, or designee. 3.The WD, AWD, or designee will ensure compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on the onsite staff record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1.The records for the following staff did not include documentation of a criminal history record issued by the Virginia Department of State Police: staff #1, staff #2, staff #3, staff #4, staff #6, staff #8, staff #9, staff #10, staff #11, staff #12, staff #13, staff #14, staff #15, and staff #16.
Plan of Correction:	1.Staff members 1,2,3,4,6,9,12,11,12,13,14,15, and 16 employment records include documentation of a criminal history record issued by the Virginia Department of State Police. 2.On September 28, 2022, an audit of employee records was completed by the Business Director (BD) and Executive Director (ED) on all current staff records, and a state police report was requested for those missing. The request for the state police check was added to the background checks completed at onboarding before orientation. 3.The BD or designee will ensure state police report completion on all new hires, new hire checklist will be filled out by BD or designee before hire. The ED or designee will review all new hire checklists before the new hire start.