VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Westminster Canterbury on Chesapeake Bay
3100 Shore Drive
Virginia beach, VA 23451
(757) 496-1100

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Feb. 4, 2020 and Feb. 5, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced renewal inspection was conducted on 02-04-2020 from 8:45 AM to 4:54 PM and on 02-05-2020 from 9:00 AM to 2:35 PM. There were 65 residents in care at the time of the inspection. A tour of the facility was conducted, water temperatures were sampled, and lunch and an activity were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident exercise drill, fire and resident emergency drills, first aid kits, medication cart, dietary and health care oversights, resident council, and the emergency food and water supply. The facility received violations "under" Administration and Administrative Services, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Emergency Preparedness. The following was discussed with the Administrator: physician's orders regarding weights and B-12 injections, UAI/ISP's, healthcare oversight dates, menus, written assurance, quarterly fire drills for all shifts, and incident reports. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the Violation Notice within 10 days of today's date, on 02-28-2020.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 01-13-2020, staff #3 emailed an incident report regarding resident #8 having a fall, resulting in a hip fracture. The report documented the incident occurred on 01-07-2020, and was not reported within 24 hours. 2. On 02-05-2020, during resident #4?s record review with staff #1 and staff #2, the direct care staff ?Clinical Note Entry? notes dated 10-26-2019 documented the resident fell, had blood on face, a knot above right eye that was starting to bruise, and bruising to both wrists. The resident was sent out to the hospital; however, the facility did not report the incident to the regional licensing office within 24 hours. 3. During interview on 02-05-2020, staff #1, staff #2, and staff #3 acknowledged the aforementioned incidents involving resident #4 and resident #8 were not reported to regional licensing office within 24 hours.
Plan of Correction:	1.Staff will be educated on reportable incidents and procedure of notification to Licensure. 2. Administrator or designee will ensure Licensure receives timely notification of such incidents in compliance with standard 22VAC40-73-(2)-70-A. 3. Administrator will audit communication book Monday- Friday for 4 weeks to ensure compliance.
Standard #:	22VAC40-73-310-D
Description:	Based on record review and interview, the facility failed to provide written assurance to the resident that the facility has the appropriate license to meet their care needs at the time of admission based on the Uniform Assessment Instrument (UAI). Evidence: 1. On 02-04-2020 and 02-05-2020, during resident record review with staff #1 and staff #2, the following residents? written assurances were completed prior to the UAI?s being reviewed: a. Resident #1 admitted to the facility on 07-29-2019. The written assurance was dated 07-25-2019 and the UAI was dated 07-26-2019. b. Resident #2 admitted to the facility on 11-15-2019. The written assurance was dated 11-14-2019 and the UAI was dated 11-15-2019. c. Resident #5 admitted to the facility on 01-23-2020. The written assurance was dated 01-22-2020 and the UAI was dated 01-23-2020. 2. Resident #1, resident #2, and resident #5?s written assurance did not document that the facility has the appropriate license to meet the residents? care needs at the time of admission based on the UAI. 3. During interview, staff #1 and staff #2 acknowledged that resident #1, resident #2, and resident #5?s written assurances were completed prior to reviewing the residents? UAI?s and did not provide written assurance to the resident that the facility has the appropriate license to meet their care needs based on the UAI.
Plan of Correction:	!.Written Assurance form was updated to match verbage in standard 22VAC40-73-(2)-70-A 2.Staff will be inserviced on completing UAI and reviewing documentation to ensure facility has the appropriate license to meet the residents care needs at the time of admission prior to the resident being admitted to Enhanced Services. 3. Administrator will review Written Assurance forms for new admission weekly x 6 weeks to ensure timely compliance with the standard.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions. Evidence: 1. On 02-05-2020, during resident #11?s record review with staff #1, staff #2, and staff #4, the physician?s order dated 11-14-2019 documented ?Start on B12 shots as follows: 1000 mcg IM daily x 7 days -> 1000 mcg IM weekly x 4 weeks -> 1000 mcg IM monthly thereafter. Would continue B12 indefinitely.? 2. Resident #11?s November and December 2019 Medication Administration Records (MAR), reviewed with staff #1, staff #2, and staff #4, documented staff administered the Cyanocobalamin B-12 injections for 6 days on 11-15-2019, and 11-17-2019 through 11-21-2019. The resident did not receive the B-12 injection on 11-16-2019. The initial weekly B-12 injection was not administered until 15 days (on 12-06-2019) after the last daily injection was administered. The remaining weekly B-12 injections were administered on 12-13-2019, 12-20-2019, and 12-25-2019. The staff administered the last weekly B-12 injection on 12-25-2019, which was five days after the injection was administered on 12-20-2019. 3. During interview on 02-05-2020, staff #1, staff #2, and staff #4 acknowledged the B-12 injections were not administered in accordance with the physician?s instructions.
Plan of Correction:	1. LPN's and RMA's will be educated to call the pharmacy after injections are given to ensure the next dose will be available. 2.. LPN supervisor will monitor injection administration scheduling in MAR to ensure injections are being administered as ordered. 3. LPN Supervisor will do a 100% audit of residents chart who currently receive B12 injections to ensure availability of injection and timely administration per the physician order.
Standard #:	22VAC40-73-680-E
Description:	Based on record review and interview, the facility failed to ensure medical procedures or treatments ordered by a prescriber are provided according to his instructions and documented. The documentation should be maintained in the resident's record. Evidence: 1. On 02-05-2020, during resident #11?s record review with staff #1 and staff #2, the prescriber?s order dated 07-16-2019 documented ?Daily weight- one time daily: Notify provider if weight increases by >2 pounds in 24hrs or >5 pounds in 1 week.? The January and February 2020 Medication Administration Records documented the resident had a weight gain of over 2lbs in 24 hours on the following days: 01-16-2020 (149.40 lbs) to 01-17-2020 (152.40 lbs); 01-31-2020 (146.80 lbs) to 02-01-2020 (151.40 lbs); and 02-02-2020 (149.00 lbs) to 02-03-2020 (152.40 lbs). Staff #1 and staff #2 could not verify and/or provide documentation that the physician was notified of the resident?s weight gain. 2. During interview on 02-05-2020, staff #2 stated the physician was not notified of the resident?s weight gain nor was there documentation of the physician being notified.
Plan of Correction:	!. Resident #11 weight change >21bs was not notified to physician as ordered on 7/16/2019. 2. 0n 2/24/2020, Residents provider was notified in writing of previous weight change findings with no new orders provided. 3. LPN's and RMA's will be educated on following physician orders per standard 22VAC40-73-(6)- 680-E and facility procedure for reporting weight changes. 4. LPN Supervisor/designee will audit notifications to providers to include timely reporting of weight changes daily x 14 days, weekly x 4 weeks.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and interview, the facility failed to ensure the fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter should not be conducted in the same month. Evidence: 1. During review of the facility?s record of required fire and emergency evacuation drills with staff #1 and staff #2, the facility has two shifts: 7:00 AM to 7:00 PM, and 7:00 PM to 7:00 AM. The following quarterly fire and emergency evacuation drills were conducted: 04-26-2019 at 1942 (7:42 PM); 05-09-2019 at 1925 (7:25 PM); 07-24-2019 at 1920 (7:20 PM); 08-14-2019 at 1911 (7:11 PM); and 09-24-2019 at 1929 (7:29 PM). The facility did not have documentation on file of a drill being conducted in March or June 2019; or during the 7:00 AM to 7:00 PM shift. 2. During interview, staff #1 and staff #2 acknowledged the facility did not conduct a fire and emergency evacuation drill in March or June 2019, or during the 7:00 AM to 7:00 PM shift for the quarters reviewed.
Plan of Correction:	1. Security staff will be educated on completing fire drills on alternating shifts monthly. 2. Administrator will audit fire drill documentation monthly to ensure compliance with standard 22VAC40-73- (9)-970-A and bring those findings to our quarterly Quality Assurance and Performance Improvement Meeting.