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. 15, 2023

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

The UAI should document the resident?s level of care as Assisted Living Care if applicable.

Comments:

Type of inspection: Renewal 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 took place on 02/15/2023 at 8:19 am to 6:30 pm. 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: 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 carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-260-A
Description:	Based on the staff record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: 1. The record for staff #2, hired 10/03/22, did not include documentation of certification in first aid.
Plan of Correction:	1.Staff #2 is scheduled to complete her first aid class on 3/6/23. 2.All direct care team members have the potential to be affected. Current team member files will be audited by Human Resources or a designee to ensure that team members have received certification in first aid within 60 days of employment or have been enrolled in a class to receive certification. 3.Human Resources or a designee will request a copy of the team member?s first aid certification upon hire or will ensure that the team member is enrolled in a first aid class to obtain certification prior to 60 days of employment. Direct care team members identified in the audit are enrolled in first aid training during the week of 3/6/23. 4.The Administrator or designee will audit current direct care team member files every two months to validate current first aid certification for a total of six months. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. Evidence: 1. Resident #1?s ISP dated 04/20/22 was not signed by the resident or the legal representative. 2. Resident # 3?s ISP dated 07/21/22 was not signed by the resident or the legal representative. 3. Resident # 5?s ISP dated 01/05/22 was not signed by the resident or the legal representative.
Plan of Correction:	1.Resident #1 had an ISP review on 1/31/23, the resident?s signature in wet ink was obtained at the time of review. Resident #3 had an ISP review on 3/1/23, and a Docusign signature was obtained by her POA. Resident #5 had an ISP review on 2/22/23, and a Docusign signature was obtained by her POA. 2.All residents have the potential to be affected. Current resident charts will be audited, and those without a signature by the resident or legal representative will have a wet signature or an electronic signature obtained through Docusign at their next scheduled review date. 3.ISP will be signed by the resident or the legal representative during their scheduled review date. The signature obtained will either be a wet signature or an electronic signature through Docusign. 4.The Administrator or designee will perform a sample audit of ISP review signature pages to validate the resident or representative signature monthly for three months. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s order and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. The record for resident # 1 contains a physician order dated (05/28/21), and a medication administration record (MAR) for Feb. 2023 includes an order for Metoprolol Tablet 25mg ?give by mouth 3 times a day Hold for Systolic Blood Pressure (SBP) less than 110, Heart Rate (HR) less than 65.? The MAR for Feb. 2023 documents the medication was not administered according to the physician order on the following dates: 02/02/20233, BP reading of 105/54; 02/10/2023, BP reading of 105/60 and HR of 62.
Plan of Correction:	1.Resident #1?s provider was notified of the occurrence cited, and Staff #2 was educated on following provider orders. Resident #1 did not experience adverse effects. 2.All residents who have blood pressure and pulse parameters for medication administration have the potential to be affected. The Director of Quality Improvement is performing an audit of potentially affected residents to identify patterns and bringing findings to the attention of the resident?s provider for order review. 3.Staff responsible for medication administration received training on exercising the rights of medication administration during medication preparation. The Informatics Manager and electronic health record account representatives evaluated electronic health record functionality for potential improvements to aid in order adherence. 4.The Director of Quality Improvement or a designee will conduct a sample audit of medication administration records to validate the administration according to ordered blood pressure or pulse parameters monthly for three months. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.