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. 9, 2023

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

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 11/09/2023 at 8:50 am to 2:45 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 11/03/2023 regarding allegations in the area 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: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: A review of resident and staff records were completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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. 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 #:	22VAC40-73-640-A
Description:	Based on the record review and staff interview the facility failed to ensure the facility shall implement a written plan for medication management to include: methods for verifying that medication orders have been accurately transcribed to medication administrator records (MARs) within 24 hours of receipt of a new order or change in an order. Evidence: 1. The facility?s medication management plan includes the following when receiving new physician orders: ?The Wellness Director of the designated Community Team Member will transcribe the order onto the existing MAR sheet for the resident in the next available space, or enter into the EMAR System, per the instructions for entering an order.? The record for resident #1 contains a physician order dated 10/19/23 that includes the following order: ?Bumex 1 mg, take 1 tab by mouth twice daily x 3days (October 19-21) then continue with 1 mg tab by mouth daily (Begin October 22). Resident #1?s MAR dated October 2023 did not include the physician order dated 10/19/23 for Bumex 1 mg. 2. Resident?s #1 incident report dated 11/02/23 documents the following: ?On 10/20/2023, Hospice wrote order for resident to receive Bumex 1mg PO BID X three days then start Bumex 1mg po QD for edema. Staff #1, RMA approved the order on 10/20/2023 for the correct start date, however the end dates were not initiated properly. The end date was initiated for 10/20/2023 for both orders.? 3. During an interview with staff #2, staff #2 confirmed resident?s #1 physician order dated 10/19/23 for Bumex 1mg was not accurately transcribed to resident?s #1 MAR.
Plan of Correction:	This Plan of Correction is submitted as required under State law. The submission of this Plan of Correction does not constitute an admission on the part of The Waterford at Virginia Beach as to the accuracy of the surveyors? findings or the conclusions drawn therefrom. The submission of this Plan of Correction does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community?s policies and procedures should be considered subsequent remedial measures, as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any judicial and/or administrative proceeding on that basis. The Community also submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies. 1.When the error was discovered on November 2, 2023, Resident #1's hospice vendor was promptly notified of the error, and a correct medication order was obtained from the prescribing physician. The corrected physician order was documented in Resident #1's MAR to accurately reflect the prescribed medication/administration. 2.On 12/8/23 an in-service was conducted to ensure accurate transcription of medication orders to Medication Administrator Records (MARs) within 24 hours of receiving new orders or changes to existing ones. The Medication Management Plan has been updated to incorporate a daily review, conducted by the Wellness Director or their designee, of new orders to ensure accuracy. In addition, the Community implemented a written plan for medication management that includes a method for verifying that medication orders have been accurately transcribed to MARs within 24 hours of receipt of a new order or change in an order. 3.For the next three months, the Wellness Director or designee will conduct weekly audits of all new orders to ensure and maintain compliance. The Wellness Director or designee will conduct daily monitoring of the medication dashboard to ensure strict adherence.
Standard #:	22VAC40-73-680-D
Description:	Based on the record review and staff interview the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #1 contains a physician order dated 10/19/23 that includes the following order: ?Bumex 1 mg, take 1 tab by mouth twice daily x 3days (October 19-21) then continue with 1 mg tab by mouth daily (Begin October 22).? Resident?s #1 incident report dated 11/02/23 documents the following: On 10/20/2023, Hospice wrote order for resident to receive Bumex 1mg PO BID X three days then start Bumex 1mg po QD for edema. Staff #1 approved the order on 10/20/2023 for the correct start date, however the end dates were not initiated properly. The end date was initiated for 10/20/2023 for both orders delaying the continuation of the medication as ordered. The resident did not receive the medication from 10/21/2023 ? 11/1/2023.? 2. During an interview with staff #2, staff #2 confirmed that resident #1 did not receive Bumex 1 mg according to the physician order dated 10/19/23 during the timeframe of 10/21/23-11/01/23. 3. Resident?s #1 MARs dated October and November 2023 did not include documentation the resident was administered Bumex 1 mg according to the physician order dated 10/19/23 during the timeframe of 10/20/23-11/01/23.
Plan of Correction:	This Plan of Correction is submitted as required under State law. The submission of this Plan of Correction does not constitute an admission on the part of The Waterford at Virginia Beach as to the accuracy of the surveyors? findings or the conclusions drawn therefrom. The submission of this Plan of Correction does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community?s policies and procedures should be considered subsequent remedial measures, as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any judicial and/or administrative proceeding on that basis. The Community also submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies. 1.When the error was discovered on November 2, 2023, Resident #1's hospice was promptly notified of the error, and a correct medication order was obtained from the prescribing physician. The corrected physician order was documented on Resident #1's MAR to accurately reflect the prescribed medication. 2.On November 16, 2023, an in-service session was held for staff members, focusing on reinforcing the procedures for reviewing and authorizing/denying medication orders within the Electronic Medication Administration Record (eMAR) system and ensuring medication is administered in accordance with the physicians or other prescriber instructions. On November 17, 2023, the pharmacy executed an audit to verify the alignment of all orders in the eMAR with the physicians? orders on file. Any discrepancies identified were thoroughly investigated and promptly rectified as necessary. 3. The Wellness Director or designee will conduct monthly audits of Medication Administration Records (MARs) over three months to ensure compliance.