Inspection Reports for The Waterford at Virginia Beach
5417 Wesleyan Dr, Virginia Beach, VA 23455, United States, VA
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 104
Deficiencies: 1
Oct 7, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to medication management, specifically the failure to implement a written plan for proper disposal of expired medications. Violations were documented and a plan of correction was requested.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure to implement a written plan for proper disposal of medication, with expired medications found on the medication cart. |
Report Facts
Number of residents present: 104
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 5
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the inspection |
| Wellness Director | Completed in-house audit of medication carts and in-service for Medication Aides related to expired medications | |
| Staff #2 | Confirmed expired medications for Residents #12 and #13 |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
May 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-11 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Complaint Details
Complaint investigation triggered by allegations related to Resident Care and Related Services and Resident Accommodations and Related Provisions. The complaint was not substantiated.
Report Facts
Number of residents present: 107
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: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Feb 13, 2025
Visit Reason
The inspection was conducted in response to complaints received by the VDSS Division of Licensing regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of Resident Care and Related Services. A violation notice was issued, including violations not related to the complaints but identified during the investigation.
Complaint Details
A complaint was received on 11/27/2024, 12/9/2024, and 2/6/2025 regarding Resident Care and Related Services and Resident Accommodations and Related Provisions. The evidence gathered supported some allegations, resulting in a violation notice.
Report Facts
Number of resident records reviewed: 5
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Feb 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2/6/2025 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of Resident Care and Related Services. A violation notice was issued, and the licensee was given the opportunity to submit a plan of correction.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services. Some allegations were not supported by the evidence gathered during the investigation.
Report Facts
Number of residents present: 107
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Dec 13, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-27 regarding allegations related to Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint related to Resident Care and Related Services and Resident Accommodations and Related Provisions; allegations were not substantiated.
Report Facts
Number of residents present: 107
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: 2
Number of observations by licensing inspector: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Oct 30, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-07 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation supported some, but not all, of the allegations, specifically identifying non-compliance in Resident Care and Related Services. A violation notice was issued related to individualized service plans not being properly signed and dated.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services. Some allegations were not supported by the evidence.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that individualized service plans were signed and dated by the licensee, administrator, or designee, and by the resident or legal representative, including documentation of contributors and dates of contribution. |
Report Facts
Residents present: 96
Resident records reviewed: 4
Staff interviews conducted: 2
Compliance date: Nov 30, 2024
Inspection Report
Renewal
Census: 96
Deficiencies: 1
Oct 17, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license, with the licensing inspector on-site for two days to review compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards related to criminal history record reports for employees, specifically that the facility did not ensure the criminal history record report was obtained within 30 days of employment for one staff member.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure the criminal history record report was obtained on or prior to the 30th day of employment for staff #3. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of interviews conducted with staff: 3
Compliance Date: Sep 18, 2024
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Jun 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 6/17/24 regarding allegations in the areas of Admission, Retention And Discharge Of Residents, and Resident Care And Related Services.
Findings
The investigation supported some, but not all, of the allegations; areas of non-compliance with standards or law were found. A violation notice was issued including violations not related to the complaint but identified during the investigation.
Complaint Details
The complaint investigation was substantiated in part; some allegations were supported by evidence while others were not. The complaint related to Admission, Retention And Discharge Of Residents, and Resident Care And Related Services.
Deficiencies (3)
| Description |
|---|
| The facility did not ensure that the fall risk rating was reviewed and updated after a fall for residents #5 and #6. |
| The facility did not ensure the Uniform Assessment Instrument (UAI) was completed on or within 7 days prior to admission for resident #6. |
| The facility did not ensure a preliminary plan of care or an Individualized Service Plan (ISP) was developed on or within 7 days of admission for residents #1 and #5. |
Report Facts
Residents present: 33
Resident records reviewed: 6
Staff records reviewed: 0
Interviews conducted with staff: 1
Observations by licensing inspector: 3
Fall incidents: 2
Compliance audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and is the contact for questions regarding the inspection |
| Executive Director | Named in plan of correction related to fall risk rating, UAI, and ISP compliance | |
| Wellness Director | Named in plan of correction responsible for completing fall risk ratings, UAI, and ISP |
Inspection Report
Monitoring
Census: 96
Deficiencies: 0
Jan 22, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the areas of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection included a tour of the physical plant, review of resident and staff records, and interviews with staff.
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 2
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Dec 19, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 2023-12-11 regarding Resident Care and Related Services and Safe, Secure Environment.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations related to medication administration without valid physician orders and failure to administer medications according to physician instructions were found.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services related to medication administration and adherence to physician orders.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure no medication was started, changed, or discontinued without a valid physician order. |
| Facility failed to ensure medications were administered in accordance with physician's instructions. |
Report Facts
Residents present: 88
Resident records reviewed: 3
Staff records reviewed: 0
Staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding the inspection |
| Lanesha Allen | Licensing Inspector | Inspector on-site during the inspection |
Inspection Report
Monitoring
Census: 88
Deficiencies: 0
Dec 19, 2023
Visit Reason
An unannounced renewal inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. Observations included a safe, secure environment and review of staff trainings, with no deficiencies noted.
Report Facts
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews conducted with staff: 3
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Dec 6, 2023
Visit Reason
An unannounced complaint inspection was conducted on December 6, 2023, following a complaint received on November 27, 2023, regarding allegations in the areas of Personnel, Resident Care and Related Services, Building and Grounds, and Safe, Secure Environment.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services and Buildings and Grounds. A violation notice was issued, including deficiencies related to medication administration and safety checks for residents unable to use signaling devices.
Complaint Details
The complaint was received by VDSS Division of Licensing on 11/27/23 regarding allegations in Personnel, Resident Care and Related Services, Building and Grounds, and Safe, Secure Environment. The evidence supported some allegations related to Resident Care and Buildings and Grounds.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician's instructions, specifically a missed medication dose for resident #1. |
| Facility failed to ensure documentation of safety rounds every two hours for residents unable to use signaling devices, specifically residents #1 and #2. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 4
Number of staff records reviewed: 1
Number of resident interviews conducted: 2
Number of staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Nov 9, 2023
Visit Reason
An unannounced complaint inspection was conducted in response to a complaint received on 2023-10-31 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified concerning staff training requirements in cognitive impairment.
Complaint Details
Complaint was received on 2023-10-31 regarding Personnel and Resident Care and Related Services. The evidence gathered did not support the allegation of non-compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure direct care staff attended at least 10 hours of cognitive impairment training within four months of employment. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Named in deficiency related to lack of cognitive impairment training within four months of hire |
Inspection Report
Monitoring
Census: 96
Deficiencies: 2
Nov 9, 2023
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards related to medication management and administration. Violations were issued for failure to accurately transcribe medication orders to Medication Administration Records (MARs) within 24 hours and failure to administer medications according to physician orders.
Deficiencies (2)
| Description |
|---|
| Failure to implement a written plan for medication management to verify accurate transcription of medication orders to MARs within 24 hours. |
| Failure to ensure medications were administered in accordance with physician's instructions, resulting in missed doses of Bumex 1 mg for Resident #1. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Donesia Peoples | Licensing Inspector | Contact person mentioned for questions about VDSS Licensing Programs |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Oct 17, 2023
Visit Reason
An unannounced complaint inspection was conducted on October 17 and 18, 2023, following a complaint received on October 10, 2023, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegation of non-compliance with standards or law. Observations included resident care activities, medication pass, and review of records and reports.
Complaint Details
Complaint received by VDSS Division of Licensing on 10/10/2023 regarding allegations in Resident Care and Related Services; investigation found no substantiated non-compliance.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 6
Resident interviews conducted: 3
Staff interviews conducted: 5
Inspection Report
Renewal
Census: 86
Deficiencies: 17
Oct 17, 2023
Visit Reason
An unannounced renewal inspection was conducted on October 17 and 18, 2023 to assess compliance with applicable standards and regulations for The Waterford at Virginia Beach assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failures in staff orientation and training, certification maintenance, resident admission documentation, medication administration records, emergency preparedness, and criminal history record checks. The facility was issued violation notices and given the opportunity to submit plans of correction.
Deficiencies (17)
| Description |
|---|
| Failed to ensure orientation and training occurred within first seven working days of employment for multiple staff. |
| Direct care certified nurse aides did not complete required 12 hours of annual training. |
| Medication aides failed to complete required continuing education annually as mandated by Virginia Board of Nursing. |
| Staff failed to maintain current certification in first aid. |
| Physical examinations were not completed within 30 days preceding admission for some residents. |
| New residents and their legal guardians did not receive documented orientation upon admission. |
| Uniform Assessment Instrument (UAI) was not completed prior to admission for some residents. |
| Preliminary plan of care or Individualized Service Plan (ISP) was not completed on or within 7 days of admission for some residents. |
| Comprehensive individualized service plans lacked required descriptions of identified needs, services, and expected outcomes. |
| Hospice care residents lacked coordinated plan of care between hospice provider and facility. |
| Resident medication orders were not signed by physician or lacked dated notation of oral orders. |
| Medication Administration Records (MAR) lacked documentation of medication administration or omissions. |
| Facility failed to provide documentation of annual review of emergency preparedness plan. |
| Facility failed to document staff participation in emergency preparedness exercises every six months. |
| Sworn statements or affirmations were missing for some staff applicants. |
| Criminal history record reports were missing or not obtained within 30 days of employment for some staff. |
| Facility employed staff with criminal history reports containing barrier crimes. |
Report Facts
Number of residents present: 86
Number of resident records reviewed: 8
Number of staff records reviewed: 6
Number of interviews with residents: 3
Number of interviews with staff: 5
Inspection Report
Monitoring
Census: 96
Deficiencies: 3
Aug 8, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in Resident Care and Related Services.
Findings
The investigation supported some but not all of the self-report; non-compliance was found in Resident Care and Related Services. Violations included failure to train direct care staff in managing aggressive residents, failure to post the on-site person in charge conspicuously, and failure to complete annual tuberculosis risk assessments for residents.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or dangerously agitated states prior to providing care. |
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Current Inspector | Named as the licensing inspector conducting the inspection |
| Wellness Director | In-serviced staff on responding to residents with inappropriate/aggressive behaviors and responsible for TB screening training | |
| Executive Director | Responsible for posting the on-site person in charge and verifying compliance |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Apr 20, 2023
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2023-04-10 regarding allegations in Resident Care and Related Services and Staffing and Supervision.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations included unlocked medication storage and failure to administer medications according to physician orders.
Complaint Details
Complaint was substantiated in part; violations related to Resident Care and Related Services were found. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were stored in a locked area; medication storage room was unlocked and unstaffed with medications on the counter. |
| Facility failed to ensure medications were administered according to physician's orders; missing documentation for medication administration and blood sugar checks for multiple residents. |
Report Facts
Number of residents present: 98
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of resident interviews conducted: 2
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Feb 2, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations related to building and grounds received on 2023-01-31.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a non-complaint related violation was identified regarding medication storage practices.
Complaint Details
The complaint was not substantiated based on the evidence gathered during the investigation.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure medications were stored in a manner consistent with current standards and the storage area was not locked; the medication cart was unlocked with a prescription bottle on top and staff accessed it without a key. |
Report Facts
Number of residents present: 96
Number of resident interviews: 3
Number of staff interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Observed exiting a resident's room and opening the unlocked medication cart without a key; received in-service training on medication storage. |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Nov 4, 2022
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2022-10-28 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The inspection included a tour of the facility, review of resident and staff records, and observations of staffing and activities.
Complaint Details
Complaint received by VDSS Division of Licensing on 2022-10-28 regarding allegations in Resident Care and Related Services. The evidence gathered did not support the allegations.
Report Facts
Number of residents present: 72
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 94
Deficiencies: 11
Sep 14, 2022
Visit Reason
An unannounced renewal inspection was conducted on September 14 and September 27, 2022, to assess compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations including failure to conduct timely reviews for residents in the special care unit, incomplete tuberculosis risk assessments for staff and residents, lack of conspicuous posting of the on-site person in charge, incomplete individualized service plans (ISP), inadequate oversight of special diets, improper medication storage, signaling device issues, and missing criminal history record reports for staff.
Deficiencies (11)
| Description |
|---|
| Failed to ensure six months and annual reviews for residents in the special care unit were completed appropriately. |
| Failed to ensure each staff person submitted tuberculosis risk assessment within seven days prior to first day of work. |
| Failed to post the name of the current on-site person in charge in a conspicuous place. |
| Failed to complete annual tuberculosis risk assessments for residents. |
| Failed to ensure ISPs included descriptions of identified needs based on Uniform Assessment Instrument (UAI). |
| Failed to ensure ISPs were signed and dated by residents or legal guardians. |
| Failed to review and update ISPs annually and as needed for significant changes. |
| Failed to ensure oversight of special diets by a dietitian or nutritionist at least every six months. |
| Failed to ensure medications were stored locked and consistent with standards; medication cart left unattended and unlocked. |
| Failed to ensure signaling device terminated at a continuously staffed central location permitting staff to determine origin of signal. |
| Failed to obtain criminal history record reports on or prior to the 30th day of employment for multiple staff members. |
Report Facts
Number of residents present: 94
Number of resident records reviewed: 10
Number of staff records reviewed: 6
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Number of residents requiring special diets documented: 16
Number of staff missing criminal history record reports: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Failed to submit tuberculosis risk assessment within required timeframe | |
| Staff #5 | Left medication cart unattended and unlocked; acknowledged signaling device issues | |
| Staff #6 | Acknowledged name of on-site person in charge was not posted; acknowledged lack of oversight of special diets | |
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding inspection |
| Lanesha Allen | Current Inspector | Conducted the inspection |
| WD | Wellness Director | Responsible for audits and monitoring compliance in multiple areas |
| WDS | Wellness Director Specialist | Involved in audits and monitoring compliance |
| AWD | Assistant Wellness Director | Involved in audits and monitoring compliance |
| BD | Business Director | Completed audits of employee records and ensured state police report completion |
| ED | Executive Director | Completed audits of employee records and ensured state police report completion |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 25, 2021
Visit Reason
A complaint inspection was initiated on 10/25/2021 to review compliance with resident care and related services standards.
Findings
The inspection determined compliance with applicable standards and laws, and no violations were documented.
Complaint Details
The inspection was complaint-related, but no violations were found and compliance was confirmed.
Inspection Report
Monitoring
Deficiencies: 0
Oct 25, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws through remote documentation review and on-site inspection.
Findings
The inspection determined compliance with applicable standards and laws, and no violations were documented.
Inspection Report
Monitoring
Deficiencies: 0
Oct 25, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws through remote documentation review and on-site inspection.
Findings
The inspection determined compliance with applicable standards and laws, and no violations were documented.
Inspection Report
Renewal
Deficiencies: 3
Oct 25, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws, including review of resident records and facility documentation.
Findings
The inspection found non-compliances related to the comprehensive service plans not including required descriptions and outcome dates, individualized service plans not signed by residents or their legal representatives, and unsecured storage of hazardous items in resident rooms.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the comprehensive service plan included description of identified need and date outcome achieved. |
| Facility failed to ensure the Individualized Service Plan was signed by the resident or his legal representative. |
| Facility failed to ensure the storage area was locked, as an unlocked cabinet containing skin wound care cleaner was observed. |
Report Facts
Resident records reviewed: 2
Audit completion deadline: Jan 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current Inspector conducting the inspection |
Inspection Report
Renewal
Census: 80
Deficiencies: 3
May 14, 2021
Visit Reason
A renewal inspection was initiated on May 14, 2021 and concluded on May 24, 2021 to assess compliance with applicable standards and laws for The Waterford at Virginia Beach assisted living facility.
Findings
The inspection identified non-compliance with standards related to placement approvals for residents with serious cognitive impairments, documentation of appropriateness of placement, and timely completion of physical examinations with allergy reaction details.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure written approval was obtained prior to placing a resident with serious cognitive impairment in a safe, secure environment. |
| Facility failed to ensure the licensee, administrator, or designee determined appropriateness of placement prior to admitting a resident with serious cognitive impairment to a safe, secure environment. |
| Facility failed to ensure physical examination by an independent physician was completed within 30 days preceding admission, including documentation of allergy reaction descriptions. |
Report Facts
Inspection dates: Inspection conducted on May 14, 2021, May 17, 2021, and May 24, 2021
Resident census: 80
Resident records reviewed: 4
Staff records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current Inspector conducting the inspection |
| Executive Director | Reported census and participated in inspection initiation | |
| Staff #1 | Confirmed lack of written approvals and documentation during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 22, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding medication administration at the facility. The investigation was conducted remotely due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The investigation found multiple violations including failure to maintain written communication records for staff, incomplete retention of resident records, and medication administration errors where medications were not administered according to prescriber's instructions.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance with standards or law related to medication administration.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a method of written communication was utilized to keep direct care staff informed; shift-to-shift notes were purged after 30 days instead of being retained for 2 years. |
| Facility failed to ensure the complete resident record was retained for at least two years after the resident leaves the facility; nursing notes were missing from discharged residents' records. |
| Facility failed to ensure medications were administered in accordance with the prescriber's instructions, resulting in a medication error where orders were transcribed incorrectly and administered incorrectly for 13 days. |
Report Facts
Medication error duration: 13
Date of resident discharge: Feb 18, 2021
Date of medication order: Jan 8, 2021
Date medication error caught: Jan 21, 2021
Date of prescriber order: Jan 7, 2021
Date of progress notes: Jan 24, 2021
Date of transition to EMAR system: Mar 8, 2021
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 29, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding medication administration and physician/prescriber orders at The Waterford at Virginia Beach.
Findings
The investigation found multiple violations including medication changes or discontinuations without valid orders, medications not administered according to physician instructions, and missing initials of staff administering medications on the Medication Administration Record (MAR).
Complaint Details
The complaint was substantiated based on evidence supporting non-compliance with medication administration and prescriber order standards.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure no medication or medical procedure was changed or discontinued without a valid order. |
| Facility failed to ensure medications were administered in accordance with physician's instructions. |
| Facility failed to ensure the Medication Administration Record (MAR) included initials of direct care staff administering medications. |
Report Facts
Inspection dates: 4
Medication administration record (MAR) missing staff initials: 32
Medication administration record (MAR) missing staff initials: 15
Medication administration record (MAR) missing staff initials: 23
Inspection Report
Complaint Investigation
Deficiencies: 4
Nov 4, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding Resident Care and Related Services and resident behaviors at The Waterford at Virginia Beach.
Findings
The investigation found multiple violations including incomplete assessments for residents admitted to the safe, secure environment, failure to update individualized service plans to reflect significant changes in residents' conditions, failure to provide ordered rehabilitative services, and lack of written policies on resident rights.
Complaint Details
The complaint was substantiated. Violations were issued based on evidence gathered during the investigation regarding resident care and behaviors.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure prior to admission to a safe, secure environment that the resident was assessed by an independent physician as unable to recognize danger or protect safety, and the assessment was incomplete in behavior/psychomotor, speech/language, and appearance. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for significant changes in residents' conditions, including documentation of aggressive behaviors and allergies. |
| Facility failed to arrange specialized rehabilitative services (PT, OT, ST) as ordered for a resident. |
| Facility failed to establish written policies and procedures for implementing resident rights as required by the Code of Virginia. |
Report Facts
Inspection dates: 5
Dates of documented incidents: 10
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