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. 27, 2024

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

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 02/27/2024 at 8:45 am to 4:00 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: 68 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, first aide kit, fire inspection report, health inspection report, and a staffing schedule. 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 #:	22VAC40-73-120-A
Description:	Based on the staff record review the facility failed to ensure the orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment. Evidence: 1. The record for staff #4, hire date 05/18/23, did not include documentation of an orientation and training completed the first seven working days of employment. 2. The record for staff #2, hire date 04/25/22, contains a completed orientation and training completed 07/16/22, which is more than seven days after staff # 2?s working days of employment.
Plan of Correction:	The Plan of Correction does not constitute an admission of liability on the part of the organization, and such liability is hereby specifically denied. The plan submission does not constitute an agreement that the inspection conclusions are accurate, constitute a deficiency, or that the application of scope and severity is correctly applied. 1. Team member #4 completed the New Hire Training checklist. 2. All team members have the potential to be affected. 3. Any team member who does not have a New Hire Training Checklist on file will participate in New Hire Training with a checklist completed for him or her. These checklists will be maintained in a binder and scanned into the personnel record. As new team members are hired, their checklists will be completed within 7 days of hire and will be added to the binder and scanned into the personnel record by the Scheduler or a designee. 4. Audits of the binder will be conducted monthly for 3 months by the Administrator or designee to ensure these checklists are present and were completed in a timely way for new hires. Audit results will be shared at least monthly at the Quality Assurance meeting. The Quality committee will review results for analysis and feedback.
Standard #:	22VAC40-73-320-A
Description:	Based on the resident record review the facility failed to ensure within 30 days preceding admission, a person shall have a physician examination by an independent physician. The report of such examination shall be on file at the assisted living facility, and shall contain the following: a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H. Evidence: 1. Resident?s #2 physical examination dated 04/18/23 does not include the following: a statement that the individual does not have a Dermal Ulcer III and IV.
Plan of Correction:	1. The physician?s statement from 4/18/23 could not be corrected. As documented on the admission skin assessment, Resident #2 did not have a dermal Stage 3 or 4 ulcer upon admission on 5/3/23. 2. All new admissions have the potential to be affected. 3. Education was conducted with team members reviewing the Report of Resident Physical Examination form to ensure all blanks are completed prior to admission. The Enhanced Services Care Coordinator and Administrator or designee will review new admission paperwork and verify all information is completed. 4. A log will be kept by the ES Care Coordinator showing new admissions and the verification of thorough completion of the Report of Resident Physical Examination. Log results will be reported at least monthly at the Quality Assurance meeting for the next 3 months. Variances will be addressed as needed. The Quality committee will review results for analysis and feedback.
Standard #:	22VAC40-73-450-A
Description:	Based on the resident record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #1, admission date of 02/16/23, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. 2. The record for resident #2, admission date of 05/03/23, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission.
Plan of Correction:	1. The service plans for the two identified residents are not able to be corrected. 2. All admissions have the potential to be affected. 3. The ES Care Coordinator and ES Clinical Coordinator were inserviced on the requirement for completing Individual Service Plans for new admissions. All new admissions going forward will have a preliminary plan of care on or seven days before admission or a comprehensive individualized service plan on the day of admission. 4. A log will be kept by the ES Care Coordinator showing the date of admission and date of completion of the service plan. This log will be reviewed at least monthly in the Quality Assurance meeting for the next 3 months. Variances will be addressed as needed. The Quality committee will review results for analysis and feedback.