Virginia DSS · Assisted Living Facility

Westminster Canterbury on Chesapeake Bay

📍 3100 Shore Drive, Virginia Beach, VA, 23451

ID 8460Two Year licenseActive
10
Inspections
On record
7
With violations
Visits that cited something
3
Clean visits
Nothing cited
25
Violations cited
Individual findings
21
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Westminster Canterbury on Chesapeake Bay was inspected 10 times between December 10, 2020 and October 30, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 25 violations under 21 distinct standards. 2 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 8 of these 10 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
03/26/2028
Administrator
Julia Fretwell
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

10

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

October 30, 2025Inspection0 violations
Inspection dates
10/30/2025
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/30/2025 10:00 am to 1:00 pm. Number of residents present at the facility at the beginning of the inspection: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the Safe Secure Unit occurred. Renovations to the unit were observed. Additional Comments/Discussion: The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 20, 2025Inspection2 violations
Inspection dates
03/20/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-250 Staff records and health requirements.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/20/2025 9:00 am to 4:00 pm. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 Observations by licensing inspector: lunch, medication pass, activity, emergency preparedness Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on the record review and interview, the facility did not ensure that a risk assessment for tuberculosis shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for resident #1 did not contain a TB screening at admission
  3. The record for resident #1 did not contain an annual TB for 2024.
  4. Staff #1 confirms the absence of the TB at admission and annual TB assessment for 2024.
Plan of correction
1. The record for resident #1 with an admission date of 02/24/2022 could not be corrected for the TB screening at admission, or the 2024 annual TB screen. An annual TB screen was completed for 2025. 2. All residents have the potential to be affected. 3. An audit was conducted, and any resident who has not completed an annual TB screen in the last year will have one completed. A tracking tool has been created, and the provider has been notified of outstanding annual TB screenings for residents. 4. Monthly audits will be conducted during chart reviews by the Clinical Coordinator or designee to validate admission and annual TB screenings are completed accordingly. The Quality committee will review the results for analysis and feedback for the next four quarters.
22VAC40-73-320-A
Based on the record review and interview, the facility did not ensure that the physical statement includes a state that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; or a statement that specifies whether the individual is considered to be ambulatory or non-ambulatory.
Evidence
  1. The record for resident #1, admission date 02/24/22, physical statement did not include whether the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; or a statement that specifies whether the individual is considered to be ambulatory or non-ambulatory.
  2. Staff #1 confirms the physical did not identify if the individual has any of the prohibited conditions or care needs or if the individual is considered to be ambulatory or non-ambulatory.
Plan of correction
1. The record for resident #1, with an admission date of 02/24/22, could not be corrected. An updated H&P was completed on 01/20/25, including designating that the individual has no conditions or care needs prohibited by 22VAC40-73-310 H and a statement specifying ambulatory status. 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 areas are completed on or within seven days prior to admission. 4. A triple check of all history and physical reports will be completed on the day of admission by ES Coordinator or designee, admitting nurse or designee, and Clinical Coordinator or designee. Variances will be addressed as needed. The Quality committee will review the results for analysis and feedback quarterly for the next four quarters.
February 27, 2024Inspection3 violations
Inspection dates
02/27/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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
22VAC40-73-450-A
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.
22VAC40-73-120-A
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.
22VAC40-73-320-A
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.
February 15, 2023Inspection3 violations
Inspection dates
02/15/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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
22VAC40-73-260-A
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.
22VAC40-73-450-E
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.
22VAC40-73-680-D
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.
October 21, 2022Complaint survey0 violations
Inspection dates
10/21/22 & 11/10/22
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 10/21/22 at 10:01 a.m. to 1:00 p.m. and 11/10/22 at 10:01 a.m. to 1:40 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint) was received by VDSS Division of Licensing on (10/20/22) regarding allegations in the area(s) of: Resident care and Related Services 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: 2 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: An observation of the special, care unit was completed. The following were reviewed: emergency preparedness drills, resident emergency drills, policy for handling resident emergencies, and a staffing schedule. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (compliant) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 21, 2022Inspection0 violations
Inspection dates
10/21/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 10/21/22 at 10:01 a.m. to 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (self-reported incident) was received by VDSS Division of Licensing on (10/12/22) regarding allegations in the area(s) of: Resident care and Related Services 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: 1 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: An observation of the special, care unit was completed. The following were reviewed: emergency preparedness and resident emergency drills; staffing schedule. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 21, 2022Inspection1 violation
Inspection dates
06/21/2022, 06/22/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced 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. A (complaint/self-reported incident) was received by VDSS Division of Licensing on (05/11/22) regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: A tour of the facility was conducted to include the memory care unit and observation of secured exits located in the memory care unit.
Violations
22VAC40-73-460-D
Based on staff interviews and documentation review, the facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care.
Evidence
  1. Per the final incident report dated 05/18/22 the resident, was not able to be located for lunch, on 05/11/22; An after action review determined the resident was able to exit the secure unit, then exited the main campus front entrance.
  2. Per an interview with staff # 1, #2, #3 and the incident report dated 05/18/22, a general services vendor who did not perceive the individual to be a resident, held open the door for the resident to exit the secure unit.
  3. Per an email sent on 06/23/22 to the Licensing Inspector from staff #1, the resident exited the secure unit at 11:27am, and left campus at 11:37am, and was located by a Cape Henry resident around 12:35pm. Per the interview with staff # 1, #2, and #3 a resident at Cape Henry apartments contacted the facility to notify them the resident was at the Cape Henry location.
  4. Per the individualized service plan (ISP), the individual has a wander guard to the R ankle; Per an interview with staff #1, #2, and #3 the resident wander guard notifies the staff on duty via page when the resident is near/leaves a secured exit door. The aforementioned staff reported the pager notified the staff when the resident exited the secure unit, however the staff did not respond. Per the aforementioned staff the staff on duty during the incident assumed the notification was received because the resident was returning from an offsite visit with his family.
  5. Per the resident ISP dated 05/17/22, the resident has a diagnosis of Alzheimers disease; the resident is disoriented to some spheres, some of the time (person, place, and time); needs supervision with mobility outside of living area.
  6. Per the Global Positioning System (GPS) Navigation the distance from the facility to Cape Henry Towers/apartments is 0.6 miles which equals to 3168 feet.
Plan of correction
1. A full campus search was initiated when it was identified that Resident #9 had exited the unit. The resident was safely located at a location his wife confirmed familiar to him due to friends residing there. Resident #9 was assessed by a Registered Nurse and Nurse Practitioner to be at baseline, in a pleasant mood, and without acute injury or distress. Visual checks at an increased frequency were initiated, the hallway security camera was changed from motion detection to continuous monitoring, and wearable GPS devices were trialed. Security and the Front Desk were provided a photograph of Resident #9. Therapeutic Recreation identified resident-centered interventions for engagement related to occupation, hobbies, and interests. Resident #9 began attending Connections at least weekly and has continued to do so since the event. 2. Residents residing in the secure memory unit have the potential to be affected. All other residents were accounted for at the time of the incident, and there has not been an elopement since the event on 5/11/22. 3.An after-action review to identify a timeline of events and root causes was performed on 5/11/22 with Administration, Therapeutic Recreation, Security, General Services, Information Technology, and Quality Management. System changes are as follows: a. The security code to the memory unit door was changed on 5/11/22 b. Vendors are supervised by General Services or a designee when providing services to the secure unit as of 5/11/22 c. SouthBay added an audible alarm to the secure memory unit door when it is opened, and a resident with a Wanderguard is within its range on 5/12/22 d. The SARA System was modified to reduce routine ambulation pager alerts so the audible alarm and alert to the pager would indicate the need to staff response on 5/12/22 e. Badge access readers replaced the key code entry pad for the secure memory unit entrance on 5/14/22 f. A Resident Emergency Practice Exercise and staff debrief were conducted on 5/12/22 g. The Emergency Operations Plan and Missing Resident policy were revised in response to these items 4. The interdisciplinary team meets at least four times weekly to review clinical systems, including wandering risk. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.
June 21, 2022Inspection7 violations
Inspection dates
06/21/2022, 06/22/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-80 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
22VAC40-90-40-B
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.
22VAC40-73-440-A
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.
22VAC40-73-970-E
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.
22VAC40-73-450-A
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.
22VAC40-80-120-E-2
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.
22VAC40-90-30-B
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.
22VAC40-73-620-B
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.
February 25, 2021Inspection7 violations
Inspection dates
Feb. 25, 2021 , Feb. 26, 2021 and March 1, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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
22VAC40-73-70-A
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.
22VAC40-73-440-A
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. de ce:
  2. 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.?
  3. 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.
  4. 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
22VAC40-73-440-D
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.
22VAC40-73-450-C
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.
22VAC40-73-650-B
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 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.
22VAC40-73-650-C
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-
  2. 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.
  3. 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.
22VAC40-73-680-D
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.
December 10, 2020Complaint survey2 violations
Inspection dates
Dec. 10, 2020 and Dec. 14, 2020
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
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 complaint investigation was initiated on 12-10-2020 and concluded on 12-14-2020. A complaint was received by the department regarding allegations in the areas of Personal Possessions. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Violations
22VAC40-73-390-A
Based on record review and interview, the facility failed to ensure the resident written agreement/acknowledgment included the required information.
Evidence
  1. Resident #1 admitted to the facility on 07-10-2018. Staff #1 provided a copy of resident #1’s ?Agreement to Transfer to Enhanced Services“ [resident written agreement] dated 07-10-2018. The ”Agreement to Transfer to Enhanced Services? did not document the required sections of the agreement as outlined in subsections A.1. A through G and A.4. A through N of this standard.
  2. Staff #1 could not provide documentation of the aforementioned information required for resident #1’s written agreement.
  3. Staff #1 stated “I provided what we had on file for [resident’s] resident agreement as of [resident’s] admission date.” Staff #1 acknowledged the facility did not have the required information documented on resident #1’s written agreement/acknowledgment.
Plan of correction
Facilities Resident Agreement form will be updated to comply with Standard Number 22VAC40-73(5)-390-A. All Residents will receive a copy of the updated Resident Agreement and the form will be used during each new admission moving forward in compliance with the standard.
22VAC40-73-550-G
Based on record review and interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident.
Evidence
  1. of this review should be the resident’s written acknowledgment of having been so informed. Evidence:
  2. Resident #1 admitted to the Assisted Living area of the facility on 07-10-2018. Resident #1’s “Admission Record” [face sheet] documented the resident is their own responsible party.
  3. Staff #1 provided documentation of resident #1’s most current annual rights and responsibilities dated 08-19-2020; however, the document was not signed by the resident. The last annual rights and responsibilities review was signed and dated by resident #1 on 08-07-2019 dated by resident #1 on 08 07 2019.
  4. Staff #1 stated “resident #1 did not attend the meeting” to review the annual rights and responsibilities and acknowledged this information was not reviewed with the resident.
Plan of correction
All residents and/ or responsible parties will receive a copy of the most up to date Rights and Responsibilities of Residents In Assisted Living Facilities In the January 2021 Resident Newsletter. A Receipt of Acknowledgement of Review will be filed In the Residents Chart. Review and Acknowledgement of Rights and Responsibilities of Residents In Assisted Living Facilities will be held annually during the Resident's Care Plan meeting with both the Resident and/or Responsible Party and filed in Residents Electronic Health Record. Resident rights will be reviewed during each Resident Council Meetings held monthly for those In attendance.