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: June 21, 2022 and June 22, 2022

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 ARTICLE 1 ? SUBJECTIVITY 22VAC40-80 THE LICENSE

Technical Assistance:

The posting of menu for all meals. The Healthcare Oversight findings to include all recommendations and to be signed and dated.

Comments:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection was initiated on 06/21/22 from 9:04am to 3:09 am and on 06/22/22 from 8:15am to 3:24pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 9 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication cart, dietary and health care oversights, emergency preparedness plan, fire inspection report, health inspection report, and a medication plan.

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on the resident record review and staff interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission, and at least annually. Evidence: 1. The record for resident #1 documents an admission date of 09/14/21. The UAI in the record is dated 11/10/21. There is no documentation in the record of a UAI completed prior to the resident admission date. 2. The record for resident #2 documents an admission date of 09/07/21. The UAI in the record is dated 12/22/21. There is no documentation in the record of a UAI completed prior to the resident admission date. 3. The record for resident #3 documents an admission date of 07/20/21. The UAI in the record is dated 11/17/2021. There is no documentation in the record of a UAI completed prior to the resident admission date. 4. The record for resident #4 documents an admission date of 06/04/19. The UAI in the record is dated 05/29/20. There is no documentation in the record of a UAI completed prior to the resident admission date. 5. Staff # 1 and Staff # 2 confirmed there is no documentation of a UAI completed prior to the admission dates for Resident #1, #2, #3, and #4.
Plan of Correction:	1. The deficient practice of not having current UAIs completed before admission, and at least annually was self-identified through quality assurance in November 2021. A plan of correction action plan was initiated at that time. Through action plan execution, a UAI was completed for Resident #1 on 11/10/21, Resident #2 on 12/22/21, Resident #3 on 11/17/2021, and Resident #4 on 12/8/21. 2. All residents admitted before this practice was self-identified had the potential to be affected. An audit was conducted on 11/3/21 to identify the most recent completion date of current residents UAIs. A new UAI Assessment was completed for all current residents by 12/17/21. Residents who have been admitted since the plan was initiated have been in substantial compliance 3. Resident Services or designee will complete a UAI prior to/on admission, annually (or every six months for the safe and secure unit), and with a significant change in status. 4. The Director of Quality or a designee will review UAI completion within the timeframes outlined in the standard during Healthcare Oversight. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-73-450-A
Description:	Based on the resident record review, the facility failed to ensure the comprehensive individualized service plan was completed within 30 days after admission. Evidence: 1. The record for resident #1 did not include documentation of a comprehensive individualized service plan (ISP) completed within 30 days after the resident admission date of 09/14/2021. The ISP in the record is documented with a completion date of 01/13/22 which is more than 30 days after the admission date. 2. The record for resident #2 did not include documentation of an ISP completed within 30 days after the resident admission date of 09/07/2021. The ISP in the record is documented with a completion date of 12/30/21 which is more than 30 days after the admission date. 3. The record for resident #3 did not include documentation of an ISP completed within 30 days after the resident admission date of 07/20/21. The ISP in the record is documented with a completion date of 02/01/22 which is more than 30 days after the admission date.
Plan of Correction:	1. The deficient practice of not having ISPs completed within 30 days after admission was self-identified through quality assurance in November 2021. A plan of correction action plan was initiated at that time. Through action plan execution, ISPs were completed for Resident #1 on 01/13/22, Resident #2 on 12/30/21, and Resident #3 had an ISP completed on 02/01/22. 2. All residents admitted before this practice was self-identified had the potential to be affected. Unless the resident was discharged before the meeting, all affected resident ISPs were updated and reviewed with the resident and/or their POA before 2/7/22. Residents who have been admitted since the plan was initiated have been in substantial compliance. 3. Residents will have an ISP completed within 30 days of admission. The Enhanced Services Coordinator and Assistant Administrator will utilize Point Click Care to track the timely completion of service plan reviews. 4. The Director of Quality or a designee will review ISP completion within the timeframes outlined in the standard during Healthcare Oversight. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-73-620-B
Description:	The facility failed to ensure the oversight of special diets included the following: a review of the physicians order or other prescribers order and the preparation and delivery of the special diet; and evaluation of the adequacy of the residents special diet and the residents acceptance of the diet; notification to the administrator of the findings and any recommendations; requirements of the subdivision of the oversite of special diets should be in writing, signed and dated by the dietician or nutritionist. Evidence: 1. The facility provided 15 resident documents titled Quarterly nutrition assessment dated 03/30/22 as evidence of their oversite of special diets. These documents were not signed and dated by the dietician or nutritionist. 2. The aforementioned assessments provided for the 15 residents did not include documentation of review of the physicians or other prescribers order and the preparation of the special diet. 3. The aforementioned assessments did not include documentation of an evaluation of the adequacy of the residents special diet and the resident?s acceptance of the diet. 4. Staff #2 acknowledged there is no documentation in writing of the administrator being advised of the findings of the oversight and any recommendations. 5. Staff #2 acknowledged the aforementioned assessments were completed by a dietician however was not signed and dated by the dietician or nutritionist.
Plan of Correction:	1. On 6/22/22, validation of electronic signatures confirmed that a dietician or nutritionist completed oversight. Confirmation was received from the dietician that oversight of special diets includes a review of provider orders. 2. All residents of special diets have the potential to be affected. Non-acceptance or concerns with the preparation/delivery are reported to the full-time dietician and addressed accordingly. Oversight of special diets was completed on 6/29 and 6/30/22, and a signed report was provided to the administrator. 3. The electronic assessment will be updated to identify the electronic signature/title of the assessor and the date. The electronic assessment will be updated to record the review of orders, the preparation/delivery of the special diet, and the adequacy/resident acceptance of the diet. The Administrator will be advised of the findings and recommendations within 10 days of completion. 4. The Director of Quality or a designee will review the recommendation summary when performing Healthcare Oversight to validate the elements outlined in the standard. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-73-970-E
Description:	Based on documentation review and interview with staff, the facility failed to ensure a record of the required fire and emergency evacuation drills included the time it took to complete the drill. Evidence: 1. The fire drill dated 05/27/22 did not document the time it took to complete the drill. 2. Staff #1 and Staff #2 acknowledged the aforementioned drill did not document the time it took to complete the drill.
Plan of Correction:	1. The security officer who conducted the drill was interviewed on 7/5/22 and determined the drill took 15 minutes to complete. An addendum with this information was attached to the 5/27/22 Fire Drill Form. 2. An audit of the fire drills completed since the last inspection to verify the time it took to complete the drill was noted on the form was completed on 7/18/22. 3. The Security Officer or designee performing the drill will complete each field on the Fire Drill Form. 4. Fire Drill Forms will be turned in to the Administrator or a designee monthly to validate each part of the form is complete. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-80-120-E-2
Description:	The facility failed to ensure certain documents related to the terms of the license are required to be posted on the premises of each facility. These are: the findings of the most recent inspection of the facility. Evidence: 1. During the onsite review of the facility the Licensing Inspector did not observe the findings from the most recent inspection to be posted in the facility. 2. Staff #1 and staff #2 acknowledged the findings of the most recent inspection of the facility was not posted in the facility.
Plan of Correction:	1. The findings from the most recent inspection were posted on each assisted living floor. 2. A tour of Enhanced Services was conducted on 7/18/22 to ensure that the findings from the most recent inspection were posted. 3. The Administrator or designee will print and post the findings from the most recent inspection as required. 4. The Administrator or designee will validate that the findings from the most recent inspection are posted monthly for three months and then quarterly for three quarters. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-90-30-B
Description:	Based on the staff record review, the facility failed to complete the sworn statement or affirmation for all applicants for employment. Evidence: 1. The Sworn statement for staff #3 dated 04/15/22 did not include documentation of responses for Questions # 2 and # 3. 2. The Sworn statement for staff #4 dated 04/15/22 did not include documentation of responses for Questions #2 and # 3.
Plan of Correction:	1. Staff #4 completed an updated sworn statement on 7/16/22 to include responses for Questions #2 and #3. Staff #3 was no longer employed at Westminster Canterbury at the time of inspection. 2. All team members have the potential to be affected. Current team member files will be audited by Human Resources or a designee to validate the fields in the Sworn Statement form are fully completed. New Sworn Statements will be obtained for those that are affected. Annual sworn statements will be collected for all current team members 3. The electronic Sworn Statement form will be revised to make responses for Questions #2 and #3 required fields 4. Human Resources or a designee will review sworn disclosures upon hire to validate that the form has been completed in its entirety before new hire orientation. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-90-40-B
Description:	Based on the staff record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. During the onsite record review there was no documentation of a criminal history record completed by the Virginia State Police for staff #3.
Plan of Correction:	1. Before beginning employment, staff #3 had a state and national background check performed by a different entity on 5/4/22. A criminal history record performed by the Virginia State Police (VSP) was obtained on 6/21/22. 2. All team members have the potential to be affected. Current team member personnel records will be reviewed to ensure that there is documentation of a criminal history record completed by the Virginia State Police on or before the 30th day of employment. A VSP criminal history record will be obtained if a team member is identified to have a record performed by an entity other than VSP. 3. Human Resources or a designee will submit and obtain a criminal history record completed by the Virginia State Police for each staff person on or before their 30th day of employment. 4. The Administrator or designee will review completed VSP criminal history records for new hires monthly with a human resources team member. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.