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: April 12, 2023 , April 13, 2023 and April 21, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-80 THE LICENSE

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: 4/12/23 9:44 am - 4:30 pm, 4/13/23 9:41 am - 6:10 pm, 4/24/23 9:50 am - 1:04 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed:5 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 4 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on record review and staff interview, the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of the resident?s continued residence in the special care unit. Evidence: 1. Resident #4?s resident record did not contain a six-month continued need for placement in the special care unit. 2. Resident #10?s resident file did not contain an annual review of continued need for placement in the special care unit. 3. Staff #1 acknowledged the aforementioned documents were not present at the time of inspection for the licensing inspector to review.
Plan of Correction:	On June 25, 2023, Executive Director performed an audit to ensure that six months after placement of the resident in the safe, secure environment, the licensee administrator or designee performed a review of the appropriateness of the resident?s continued residence in the special care unit. Executive Director also audited to ensure annually thereafter, the licensee, administrator, or designee performed a review of the appropriateness of the resident?s continued residence in the special care unit. All memory care residents have received a review of appropriateness to date. Going Forward, licensee, administrator, or designee should review appropriateness of placement when UAI and ISP is updated at 6-month mark and every 6 months thereafter.
Standard #:	22VAC40-73-320-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Resident files provided for Residents #5, #6, and #7 did not contain TB assessment forms which were completed annually. 2. Staff #1 acknowledged updated TB assessment forms were not available for licensing inspector to review at the time of the inspection.
Plan of Correction:	For resident #6, we completed a T.B. risk assessment 6/27/23. By the time we received the inspection summary, resident #5 and #7 had been discharged. Going forward every month, my Director of Health Services and/or designee will confirm upcoming annual TB dates by the resident?s respective yearly date due. Either the Resident?s doctor and/or Director of Health Services (L.P.N.) and/or Licensed Designee will perform the annual T.B risk assessment to ensure compliance.
Standard #:	22VAC40-73-325-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. Evidence: 1. Resident #4 had documented falls on 6/27/22, 9/10/22, 8/12/22, 8/29/22, 9/25/22, 9/28/22 and there were no corresponding fall risk assessments completed in the resident?s file. 2. Staff #6 acknowledged there were no fall risk assessments for the documented falls in the resident file which was provided to the licensing inspector to review
Plan of Correction:	Fall risk assessments shall be completed after every fall. We have implemented a fall risk assessment into our electronic MARS system. Going forward, with every documented fall, Director of Health Services and/or designee will be alerted to complete a fall risk assessment to ensure compliance. Every week, the Director of Health Services will audit all falls at the weekly Quality Assurance Meeting to make sure fall risk assessments are complete in the MARS. This is ongoing.
Standard #:	22VAC40-73-430-H-1
Description:	Based on review of resident record, the facility failed to ensure that a discharge statement included all the required information listed in the standards to be provided to the resident and as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: 1. Resident # 9?s discharge statement dated 8/8/22 was blank in the following area: date discharge statement provided to legal representative/designated contact person. 2. Resident #8?s file did not contain a discharge statement.
Plan of Correction:	Executive Director provided the date that the discharge statement was provided to legal representative/contact person for resident #9 on 6/27/23. Executive Director completed resident #8?s discharge summary 6/27/23. Going forward, prior to discharge, Executive Director and/ or designee will document conversations, interactions, statements, and documentation with legal representatives/designated contact persons on the required discharge statement. Executive Director and/or designee will complete form (with signature) in its entirety.
Standard #:	22VAC40-73-440-B
Description:	Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee. Evidence: The UAI for Resident #1 dated 7/7/2022 did not contain an administrator or administrator?s designee signature.
Plan of Correction:	Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee Administrator and/or the Administrator?s designee are signing immediately after care plan meetings with the family to ensure all UAI?s are approved and signed by the administrator and/or administrator?s designee. Director of Health Services and/or designee will audit all UAI?s by 7/7/23 to ensure that all are signed by Administrator or designee and brought current by 7/7/2023.
Standard #:	22VAC40-73-450-F
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: The ISP for Resident #4 did not contain the resident?s identified allergies.
Plan of Correction:	Resident #4?s ISP was corrected immediately. Following inspection, Director of Health Services and Resident Care Coordinator audited every resident?s ISP to ensure allergies were listed appropriately. Director of Health Services or designee will audit 3 ISP/UAI?s a day at Clinical Review Meeting to ensure all ISP?s reflect resident care needs. Furthermore, every month the Director of Health Services will pull monthly report from MARS to audit ISP?s and ensure their allergies are reflected within.
Standard #:	22VAC40-73-580-A
Description:	Based on a review of facility documentation the facility failed to ensure that it obtained an annual inspection report from the Virginia Department of Health. Evidence: The facility provided documentation of a health inspection report from the Virginia Department of Health last dated 12/12/2021.
Plan of Correction:	The previous Administrator contacted the Department of Health on 2/20/23 and provided documentation that we have one but until they inspect, they will not send the new permit. The Department of Health stated that we are on the list, and they will get to us when they can. The previous Executive Director noted that there were follow-ups on multiple occasions. On 6/21/23 and 6/27/23, Executive Director reached out to multiple contact numbers. ED was able to leave a message on 6/27/23 at 11:44am at contact number listed on the last health department permit and also left message for Business Office. On 6/27/23, Executive Director spoke with ******** at 2:30pm. He stated he needed to go through the database and would call back. He acknowledged they were very backed up and it was not our fault. At 3:27 pm on 6/27/23, the Health Inspector arrived to perform his inspection. Please see attached permit.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation and interview, the facility failed to ensure the medicine cabinet or compartment used for storage of medications is locked. Evidence: 1. During the medication cart audit on 4/12/2023 with Staff#1, the medication cart on the memory care unit was unattended and unlocked. 2. Staff #1 acknowledged the medication cart was unlocked and unattended.
Plan of Correction:	Following the Med Cart Audit by licensing inspector, the employee was addressed immediately. Starting 6/12/23, Assisted Living and Memory Care have random daily cart audits to ensure carts are locked when unattended and keys are on person administering the medications. Furthermore, Director of Health Services and Memory Care Director conduct weekly med cart audits, in addition to quarterly med cart audits conducted by community pharmacy. This will be a weekly process.
Standard #:	22VAC40-73-680-C
Description:	Based on observation, the facility failed to ensure medications be administered no earlier than one hour before and no later than one hour after the facility?s standard dosing schedule, except for those drugs that are ordered for specific times. Evidence: 1. On 4/12/23, during medication observation pass with Staff #1, Staff #3 was observed administering the following 9:00am medications to Resident #1 at 10:31am: Cranberry 425mg, Ezetimibe 10mg, Fenofibrate 54mg, Fexofenadine 180mg, Preservision soft Gel, and Vitamin D3 1000IU. 2. On 4/12/23, during medication observation pass with Staff #1, Staff #3 was observed administering the following 8:00am medications to Resident #11 at 10:42am: Acetaminophen 325 mg, Aspercrm/Lido 4% patch, Atorvastatin 20mg, Docusate SOD/Senna, Folic Acid 1 mg, Midodrine HCL 5mg, and Vitamin B-12 1,000 mcg.
Plan of Correction:	Every day, Director of Health Services, Memory Care Director, Executive Director, and Director of Operations review the previous day med pass to ensure every medication is administered within the communities dosing schedule, except for the drugs that are ordered for specific times. By 6/28/23, all Memory Care medications will be scheduled for 8:30,12:30,4:30pm,9pm unless drugs are ordered for specific times, to ensure medications are administered no earlier than one hour before and no later than one hour after the facilities dosing standards. By 6/31/23, all Assisted Living medications will be scheduled for 8:30,12:30,4:30pm,9pm unless drugs are ordered for specific times, to ensure medications are administered no earlier than one hour before and no later than one hour after the facilities dosing standards. This will be monitored on an ongoing basis by the DHS, MCD and ED.