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. 25, 2021 , Feb. 26, 2021 and March 1, 2021

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 02-25-2021 and concluded on 03-01-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 66. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, and dietary oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

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. Resident #1?s ?Progress Notes? [nursing notes] dated 02-11-2021 documented ?? resident noted on the floor laying on [resident] right side in fetal position? resident noted with small laceration to right lateral side of head? laceration area is noted with purplish color bruise and slight bleeding noted? sending to ER? DX [diagnosis] of scalp laceration with 4 staples noted?? The regional licensing office did not receive an incident report from the facility regarding the aforementioned incident. 2. Staff #1 and staff #2 acknowledged the aforementioned incident was not reported to regional licensing office.
Plan of Correction:	1. After further review and clarity of the standard and technical assistance regarding incident reporting, an incident report for Resident #l 's incident will be submitted to the regional licensing office on 3/15/21 2. Staff will be educated on reportable requirements to Regional Licensing Office 3. Hospital Transfers will be reviewed by the Administrator and/or Director of Quality Management to determine if a report to the licensing office is warranted. Findings will be reviewed in our Quality Assurance and Performance Improvement meetings.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed whenever there is a significant change. Evidence: 1. Resident #1?s ?Progress Notes? [nursing notes] documented: A. 12-29-2020- ?? was assisted to the bathroom by RMA, pull up changed?? B. 12-30-2020- ?? RMA assisted with getting undressed and using urinal? resident used urinal and pull up was changed?? C. 01-03-2021- ?? Pull-up was changed by RMA?? D. 02-14-2021- ?Resident stayed in bed? did not used urinal, incontinent, pull-up was changed.? 2. Resident #1?s current UAI dated 09-30-2020 documented the resident does not need assistance with toileting or incontinence; and was not updated to reflect the type of assistance needed for the aforementioned needs. 3. Staff #1 and staff #2 acknowledged resident #1?s UAI was not updated.
Plan of Correction:	1. Residents UAI will be updated to reflect current status 2. UAI Trained team members will monitor assigned resident 's documentation and care needs for changes that would require UAI updates. 3. Director of Quality Management or designee will review UAI and ISP accuracy during Quarterly Clinical Oversight and on an as needed basis. Findings will be reviewed in our Quality Assurance and Performance Improvement meetings
Standard #:	22VAC40-73-440-D
Description:	Based record review and interview, the facility failed to ensure that Uniform Assessment Instrument (UAI) was completed as required by 22VAC30-110. Evidence: 1. Resident #1?s current UAI dated 09-30-2020 and resident #3?s current UAI dated 02-04-2020 did not include the name or signature of the Assessor who completed the UAI. 2. In addition, resident #3?s UAI documented the resident is dependent in two ADL?s (dressing and wheeling), and was assessed for residential level of care instead of assisted living level of care. 3. Staff #1 and staff #2 acknowledged resident #1 and resident #3?s UAI?s were not completed as required.
Plan of Correction:	1. Current Residents (Resident #l's UAls were reviewed and updated, to include the designated level of care and an Assessor and Designee. 2. A UAI trained team member will complete the UAI and the Administrator or designee will cosign the assessment. 3. Director of Quality Management or designee will review the level of care and the presence of both signatures on UAI assessments during Quarterly Clinical Oversight and on an as needed basis. Findings will be reviewed in Quality Assurance and Performance Improvement Meetings.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. Resident #1?s UAI dated 09-30-2020 documented wanders/passive behaviors weekly or more; however, the current ISP dated 09-30-2020 did not include documentation of wandering behaviors. The ?Goal Dates? (expected outcome dates) were also dated 08-21-2020 and 09-01-2020 and were not updated to reflect the current outcome dates. 2. Resident #3?s UAI dated 02-04-2020 documented the need for physical assistance with dressing; however, the current ISP dated 02-12-2020 documented the resident is independent with dressing. 3. Resident #4?s UAI dated 01-28-2019 documented the need for mechanical assistance with bathing; however, the current ISP dated 01-10-2020 did not include the mechanical device needed for bathing. 4. Resident #1, resident #2 (ISP dated 02-10-2021), resident #3, and resident #4?s ISP?s did not include the date identified for each individual need. 5. Staff #1 and staff #2 acknowledged the aforementioned ISP?s did not include a description of the resident?s identified needs.
Plan of Correction:	1. Current Residents (Resident #1, Resident #2) UAls were updated to reflect current needs. Identified dates of the resident's needs are documented on the ISP in the current electronic medical record. 2. UAI Trained team members will monitor assigned resident's documentation and care needs for changes that would require UAI and ISP updates. Once updates are performed, the Administrator or designee will cosign the UAI and review the ISP for accuracy. 3. Director of Quality Management or designee will review UAI and ISP accuracy during Quarterly Clinical Oversight and on an as needed basis. Findings will be reviewed in our Quality Assurance and Performance Improvement meetings.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure the physician?s orders for administration of all prescription and over-the-counter medications identified the diagnosis or specific indications for administering each drug. Evidence: 1. Resident #2?s signed physician?s orders dated 12-30-2020 did not include a diagnosis or specific indications for administering the following medications: Allopurinol 100mg; Amiodarone 200mg; Ativan 0.5mg; Atorvastatin 20mg; Cholecalciferol Chewable 50mcg; Coenzyme Q-10 100mg; Furosemide 20mg; Gabapentin 300mg; Lidocaine 5% patch; Magnesium Oxide 400mg; Metolazone 2.5mg; Metoprolol 25mg; Polyethylene Glycol 17gm; Acetaminophen 325mg; and Tramadol 50mg. 2. Resident #4?s signed physician?s orders dated 01-15-2020 did not include a diagnosis or specific indications for administering Hydromorphone HCL 2mg and Gabapentin 300mg. 3. Staff #1 and staff #2 acknowledged resident #2 and resident #4?s physician?s orders did not include a diagnosis or specific indications for administering the aforementioned drugs.
Plan of Correction:	1. Orders for Resident #2 and Resident #4 have diagnosis and indications for use. Staff determined a transition error from implementation from one EMR to another that has since been corrected. An audit was performed on 3/5/21 and all current residents have a diagnosis or indication for each order. 2. Licensed Nurses will confirm that a diagnosis or indication for use will be associated with orders entered into the electronic medical record. If documentation from the provider does not indicate these, the order will be clarified. 3. The Director of Quality Management will audit 100% of new orders for diagnosis or indication for use weekly for one month and then twice monthly for two months. Findings will be reported and reviewed in monthly QAPI Meetings.
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician's oral orders are reviewed and signed by a physician within 14 days. Evidence: 1. The following physician?s oral orders were not reviewed and signed by a physician within 14 days: A. Resident #1?s orders dated 10-24-2020 for Metamucil, Acetaminophen 500mg, Escitalopram 5mg, Potassium Chloride 20meq, Vitamin E; and Mirtazapine 15mg (order dated 09-21-2020) were not reviewed and signed until 12-21-2020. Additional orders dated 01-17-2021 for Melatonin 10mg and Furosemide 40mg were not reviewed and signed until 02-11-2021. B. Resident #2?s orders for Miconazole Nitrate Cream 2% (order dated 12-17-2020); Atorvastatin20mg (order dated 09-29-2020); Gabapentin Capsule 300mg (order dated 10-03-2020); Lorazepam 0.5mg (order dated 10-05-2020); Diphenhyrdramine 25mg (order dated 10-09-2020); and Tramadol 50mg (order dated 12-04-2020) were not reviewed and signed until 02-03-2021. C. Resident #3?s orders dated 10-03-2020 for Vitamin B-12 500mcg, Furosemide 40mg, Furosemide 20mg, and Potassium CL 20meq; and orders dated 10-04-2020 for Pilocarpine Oth Soln 2% and Dorzolam/Timolol Opth soln were not reviewed and signed until 02-23-2021. 2. Staff #1 and staff #2 acknowledged the aforementioned verbal orders were not reviewed and signed by a physician within 14 days.
Plan of Correction:	1. Current Residents (Resident #1, Resident #2) UA ls were updated to reflect current needs. Identified dates of the resident's needs are documented on the ISP in the current electronic medical record. 2. UAI Trained team members will monitor assigned resident's documentation and care needs for changes that would require UAI and ISP updates. Once updates are performed, the Administrator or designee will cosign the UAI and review the ISP for accuracy. 3. Director of Quality Management or designee will review UAI and ISP accuracy during Quarterly Clinical Oversight and on an as needed basis. Findings will be reviewed in our Quality Assurance and Performance Improvement meetings.
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. Resident #2?s current signed physician?s orders dated 12-30-2020 documented, ?Ativan by mouth 0.5mg- 0.5mg tab 2 times a day PO ? tablet in AM and 1 tablet in PM.? 2. Resident #2?s February 2021 Medication Administration Record (MAR) documented staff administered Lorazepam 0.25mg [Ativan] two times a day (8:00 AM and 8:00 PM) on 02-01-2021 through 02-24-2021. The MAR did not include documentation indicating the resident received 1 tablet of Lorazepam 0.5mg in the evening. 3. Staff #1 could not provide a physician?s order documenting to change the Lorazepam to 0.25mg two times a day. 4. Staff #1 and staff #2 acknowledged resident #2?s Lorazepam 0.5mg was not administered in accordance with the physician?s instructions.
Plan of Correction:	1. Resident #2's current order for Ativan 0.25mg BID that began on 10/6/20 is consistent with physician's orders received by the community on 10/ 6/ 20. 2. Licensed Nurses will continue to confirm that orders transcribed into the medical record match the verbal or written order provided. 3. The Director of Quality Management will review 100% of new orders transcribed from a written order sheet for accuracy weekly for one month and twice weekly for two months. Findings will be reviewed in monthly QAPI meetings.