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: Aug. 8, 2023

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 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 08/08/2022 from 9:35 am to 12:48 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 07/03/2023 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity in the safe, secure unit was observed Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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. 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 #:	22VAC40-73-270-1
Description:	Based on the record review and staff interview the facility failed to ensure direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. Evidence: 1. The record for resident #1 contains a Uniform Assessment Instrument (UAI) and Individualized Service Plan (ISP) dated 06/20/23 that documents aggressive behaviors. The record for resident #2 contains a UAI and an ISP dated 06/29/23 that documents a history of aggressive behaviors. The records for staff #1 (hire date 01/26/23) and staff #2 (hire date 06/22/22) did not contain documentation of training in methods of dealing with residents who have a history of aggressive behaviors. Staff #1 and Staff #2 were scheduled to provide direct care to residents #1 and #2 on 06/30/23.
Plan of Correction:	Staff member #1 no longer works at the community. Staff member #2 was in-serviced by the Wellness Director on August 17,2023 on Responding to Residents with Inappropriate/aggressive behaviors. August 17,2023 the Wellness Director in-serviced staff during an all staff meeting on Responding to Residents with Inappropriate/aggressive behaviors. Staff that were unable to attend the all-staff meeting will receive the above in-service by September 1, 2023. Wellness Director/designee will complete training on all direct care staff during orientation. The Business Director/designee will review the direct care staff file prior to their first day on the floor to ensure the above training has been completed.
Standard #:	22VAC40-73-290-B
Description:	Based on 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. During a tour of the facility a posting of the on-site person in charge was not observed to be posted in the facility. 2. Staff #3 acknowledged a posting of the on-site person in change was not posted in the facility.
Plan of Correction:	The Executive Director immediately posted the current on-site person in charge once it was identified by the State Surveyor. The Receptionist posts the on-site person in charge daily. The Executive Director/Wellness Director will verify the on-site person in charge is posted as per state regulation Monday through Friday, the Manager on Duty will verify the on-site person in charge is posted Saturday and Sunday.
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 #1 contains a risk assessment for TB dated 07/16/21. The record does not contain documentation of a risk assessment for TB completed after 07/16/21. 2. The record for resident #2 contains a risk assessment for TB dated 02/23/15. The record does not contain documentation of a risk assessment for TB completed after 02/23/15.
Plan of Correction:	Residents #1 and #2 had a Tuberculosis (TB)screening completed on August 15, 2023. The Wellness Director/designee will complete a new Tuberculosis (TB) screening on all residents by August 31,2023. The Wellness Director/designee will complete Tuberculosis (TB) screening on residents by August 31st annually and keep findings in a TB log.