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: Oct. 2, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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

Comments:

Type of inspection: Complaintx Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 9/14/2022 & 9/22/2022 regarding allegations in the area(s) of: Staffing and Supervision Resident Care Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 18 Memory Care Unit The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed activities, toured several resident rooms, took water temperature, and observed breakfast. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care A violation notice was issued; any violation(s) not related to the (complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident. Evidence: Resident #4?s most recent TB assessment was dated 9/30/2021, and Resident #5?s most recent TB assessment was dated 7/01/2021.
Plan of Correction:	All charts have been audited and tickler file created with due for TB risk assessment dates as of 2/8/23 Set up a plan with NP who visits to get all TB risk assessment completed. DON or designee to audit 3 charts week to ensure all TB assessments are updated for period of 3 months with finds reported at weekly quality assurance meeting.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident records reviewed, the facility failed to ensure a fall risk rating was updated after a fall. Evidence: 1. Resident #2 had a documented fall on 7/28/22 and there was no updated fall risk assessment completed. 2. Resident #1 had a documented fall on 9/28/22 and there was no updated fall risk assessment completed. 3. Resident #5 had documented falls on 7/19/2022, 8/2/2022, and 8/29/2022. There were no updated fall risk assessments completed.
Plan of Correction:	DON to audit all falls at weekly Quality Assurance meeting for the next 3 months to ensure fall risk assessments are completed. Fall risk assessment to be completed after every fall. DON or designee to audit full month of FEB 2023 to ensure all Fall risk assessments are completed.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record review, the facility failed to have the ISP (Individualized Service Plan) signed by the resident or his/her legal representative. Evidence: Resident #5 has an ISP dated 12/31/2021. There was no signature of the resident or the resident?s legal representative.
Plan of Correction:	Audit all ISPs by March 5th to ensure that all parties have signed the ISP At care plan meetings all ISP need to be signed by resident and responsible party
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified. Evidence: 1. Resident #5?s ISP dated 12/31/2021 did not document the resident?s physical therapy services. 2. Resident #5?s Uniform Assessment Instrument (UAI) assessed the resident as needing mechanical and human assistance in bathing. The ISP does not indicate what type of mechanical assistance the resident requires. 3. Resident #5?s UAI assessed the resident as needing mechanical and human assistance with toileting. The ISP does not indicate what type of mechanical assistance the resident requires.
Plan of Correction:	Ensure all ISP?s have been updated as required to reflect resident needs. DON or designee will audit 4 ISP/UAI weekly for 3 months and report all findings to QA meeting weekly. Ensure any resident with COC has an update ISP/UAI
Standard #:	22VAC40-73-550-G
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident?s record. Evidence: The record for Resident #4 contained a most recent resident rights review signed 9/28/2021.
Plan of Correction:	All resident charts to be audited for completed resident rights by 2-24-23. All residents will have a completed and signed Resident Rights BY March 1st follow up to be reported at weekly QA meeting. Life Enrichment Director will create a tickler file to ensure resident?s rights are updated monthly.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to implement a written plan for medication management. Evidence: 1. Resident #2 refused 135 medications in September 2022. 2. Resident #4 refused 50 medications/treatments in September 2022.
Plan of Correction:	All medication techs and nurses must be trained on notifying families and doctors of refusals of medications, and it must be documented that the notifications were completed- training by March 1st for all medication staff / nurses Don or designee shall audit MARS weekly at the QA meeting to ensure families and doctors have been notified of refusals this shall be done for a period of three months with all findings documented in the quality assurance meeting minutes