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: Dec. 6, 2023

Complaint Related: Yes

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 12/06/23 at 9:05 am to 1:28 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint) was received by VDSS Division of Licensing on (11/27/23) regarding allegations in the area of: Personnel, Resident Care and Related Services, Building and Grounds, and Safe, Secure Environment. Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 1 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the safe, secure environment and a review of the staffing schedule was completed. 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 allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Buildings and Grounds A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on the record review 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 11/29/23 that documents the following instructions: ?tobramycin eye sol. Instill two drops to left eye every 4 hours for 3 days.? Resident?s #1 Medication Administration Record (MAR) for Nov. and Dec. 2023 documents the resident was administered tobramycin on 12/01/23 and 12/02/23. The record for resident #1 including the MAR did not include documentation tobramycin was administered to the resident for 3 days according to the physician order.
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. Upon identifying a medication error, corrective measures were promptly initiated. On 12/7/23 the resident?s physican was promptly notified about the missed medication, and efforts were made to obtain any necessary additional orders as part of the plan for correction. 2.On 12/7/23, all medication aides underwent an an inservice session focused on adhering to doctor's orders and ensuring proper medication administration. Subsequently, on 12/7/23, an audit was conducted for all resident medications administration records (MARs) to verify that no other medications were overlooked. Any identified missed orders were promptly addressed through communication with the physician, and new orders were promptly implemented as part of the corrective action plan. 3.The Wellness Director or designee will conduct weekly audits of (MARs) for the next three months. This ongoing process aims to verify the accurate implementation of orders and prevent any instances of medication omission.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years. Evidence: 1. Resident?s #1 Individualized Service Plan (ISP) dated 06/29/23 documents a diagnosis of Dementia and includes the following: ?perform safety checks as scheduled for resident every two hours, 12x per day.? Resident?s #1 record did not include documentation rounds were made for Nov. 2023. 2. Resident?s #2 ISP dated 04/18/23, 06/20/23, and 12/05/23 documents a diagnosis of Vascular Dementia and includes the following: ?perform safety checks as scheduled for resident every two hours.? Resident?s #2 record did not include documentation rounds were made for Nov. 2023.
Plan of Correction:	1.On 12/12/23, a new rounding sheet was implemented to facilitate 2-hour checks on all residents who are unable to use the signaling device. This initiative is designed to enhance monitoring and ensure the well-being of residents with communication challenges. 2.On 12/12/2023, an in service session for all direct care staff was conducted to ensure the proper implementation of the new rounding sheet and to familiarize staff with the protocol for conducting 2-hour checks on residents unable to use the signaling device. This training aimed to reinforce the importance of consistent and attentive monitoring for the well-being of residents. 3.The Wellness Director or designee will conduct weekly audits of the rounding sheets over the next three months to verify and ensure compliance with the established protocols for 2-hour checks on residents unable to use the signaling device.