VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Edgeworth Park at New Town
5501 Discovery Park Boulevard
Williamsburg, VA 23188
(757) 345-5005

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: June 7, 2022 and June 10, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/07/2022 from 8:30 am to 2:20 pm and 06/10/2022 from 8:51 am to 10:13 am. 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: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Observations by licensing inspector: First aid kit inspected, medication pass observed, and required postings reviewed. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observation and discussion, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR is be posted in the facility. Evidence: 1. On 06-10-2022, Staff #8 acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.
Plan of Correction:	On 6-10-2022 staff member #8 corrected on site. Posted a list of all staff who are CPR and First Aid certified. Executive Director educated staff about the regulation at staff meeting held on 6/22/2022. Educated staff of the importance and where it is posted. Monthly the Director of Health Services will audit the CPR and first aid is posted. This will be reviewed monthly at Quality Assurance meting for next 4 months.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement methods to prevent the use of outdated, damaged, or contaminated medications. Evidence: 1. During a medication pass observation with Staff #4 for Resident #4 on 06-07-2022, one of the medications, Probiotic Pearl 1B capsule, fell on the floor of the resident?s apartment. Staff #4 was observed to pick it off of the floor and place it back into the cup with the remaining medications for Resident #4 to take.
Plan of Correction:	The protocol for the destruction of a contaminated medication has been reviewed with staff #4. In order to ensure compliance with the regulation, an in-service on proper medication pass will be performed by Director of Health Services by 7/22/2022 for all nurses and medication technicians to ensure compliance. Director of Health service will do 2 random monthly medication pass audits for the next 3 months to ensure compliance and report findings at the monthly Quality Assurance meeting.