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. 19, 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 REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

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 12/19/23 at 9:15 am to 12:35 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 (12/11/23) regarding allegations in the area of: Resident Care and Related Services, 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the safe, secure environment 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. 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 #:	22VAC40-73-650-D
Complaint related:	No
Description:	Based on the record review the facility failed to ensure no medication, shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over the counter, and sample medications. Evidence: 1. The record for resident #2 contains a Medication Administration Record (MAR) for Nov. 2023 that includes instructions for ?Diazepam tab 2mg take 1 tablet by mouth three times a day, date written 11/24/23, stop date 11/27/23.? The Nov. MAR documents resident #2 was administered Diazepam 2mg on 11/25/23-11/27/23. Resident?s #2 record does not contain a written physician order to start Diazepam 2mg, 1 tablet 3 times a day on 11/24/23 and to change or discontinue Diazepam 2mg on 11/27/23.
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.Upon identifying a medication error, corrective measures were promptly initiated. On 12/19/23 the resident?s physician was promptly notified about the medication error, and efforts were made to obtain any necessary additional orders as part of the plan for correction. 2.On January 5, 2024, an in-service was conducted for staff to address the medication administration process and adherence to doctor's orders. A review of all Medication Administration Records (MARs) was undertaken to ensure compliance with the administration of all other medications. 3.The Wellness Director or their designee will perform weekly audits of all Medication Administration Records (MARs) for the next three months. This continuous process is intended to confirm the accurate implementation of orders and prevent any occurrences of medication omission. Additionally, the Wellness Director will conduct a weekly review of doctors' orders.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
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 #2 contains a physician order dated 11/26/23 that documents the following instructions: ?Ampicillin 500mg, take 1 capsule every six hours for 5 days.? Resident?s #2 Medication Administration Record (MAR) for Nov. 2023 documents the resident was administered Ampicillin 3 times on 11/30/23. The resident?s MAR did not include documentation Ampicillin was administered to the resident at the scheduled time of ?PM? on 11/30/23.
Plan of Correction:	1.On 12/19/23, upon discovering the missed dose of Ampicillin, the resident's physician was promptly informed to inquire about any additional orders. No adverse effects were observed. 2.On January 5th, 2024, an in-service session was conducted with the staff to address omissions in the Medication Administration Records (MAR) and emphasize adherence to doctors' orders. Subsequently, an audit of all MARs was carried out to ensure strict compliance with doctors' orders. 3.The Wellness Director or their designee will perform weekly audits of all Medication Administration Records (MARs) for the next three months. This continuous process is intended to confirm the accurate implementation of orders and prevent any occurrences of medication omission. Additionally, the Wellness Director will conduct a weekly review of all doctors' orders.