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: Dec. 6, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

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: 12/6/2023 9:21am- 1:50 pm 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 11/25/2023 regarding allegations in the area(s) of: Personnel Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 78 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: 4 Number of interviews conducted with residents: Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were 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. 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 Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on the audit of the medication cart, review of facility records, and interviews conducted the facility failed to implement a written plan that ensured that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 12/6/23, during the on-site inspection, Resident #5?s PRN Ondansetron 4 mg tablets were not present. Resident #6?s PRN Flonase was not present. Resident # 7?s PRN Acetaminophen 325 mg, Meloxican 7.5 mg, and Polyethylene Glycol were all not present. 2. A review of the Medication Administration Record (MAR) for November 2023 documented the following residents? medications were not able to be administered because the medications were not available. Resident #5?s Advair was not available to be administered on 11/11/23, 11/12/23/, and 11/16/23. Resident #6?s Lidocaine Pain Relief patch was not available to be administered on 12/3/23. Resident # 7?s Fluticasone nasal spray was not available to be administered on 11/4/23 and 11/23/2023. Resident #9?s Humalog Kwik Pen was not available to be administered on 11/27/23, 11/28/23, and 11/29/23.
Plan of Correction:	On 12/27/23, all medication aids received an in-service on re-ordering medications to avoid missed dosages. Medication aids will reach out to dispensing pharmacy at least 7 days prior to medications running out. Implemented a medication tech to medication tech binder for communication regarding reminder and follow up calls/faxes to pharmacy. Medication aids gained access in our electronic medical record system to request refills from pharmacy. On 2/7/24, medication aids received another in-service on medication refill policy. During this in-service, the community also implemented a procedure for medication aids who are unable to find a medication during their shift. All medication aids must call either the Resident Care Coordinator or Memory Care Director to avoid missed dosages. Every morning, the clinical team, Executive Director, and Director of Operations review the previous day medication pass to follow up on any outstanding refills and missed medications.
Standard #:	22VAC40-73-660-A
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure that all medications and dietary supplements were stored in a manner consistent with the current standards of practice. Evidence: 1. During the on-site inspection on 12/6/2023, Licensing Inspectors observed a bottle of Boost unsecured and unattended on the shelf of a table outside of the nurses? station near the first-floor medication cart. 2. Staff #3 acknowledged the Boost was unsecured.
Plan of Correction:	Executive Director, Director of Health Services performing routine audits during walk of building to ensure boost is stored properly. By 3/8/24, medication aids will receive an in-service to ensure that all medications and dietary supplements are stored in a manner consistent with the current standards of practice. Staff number 3 addressed on day of inspection to ensure boost is not left unattended in the community.
Standard #:	22VAC40-73-660-A-7
Complaint related:	No
Description:	Based on observations made during the medication cart audit, the facility failed to properly label single-use and dedicated medical supplies. Evidence: The glucometer for Resident #9 was not labeled and the bag for the glucometer was present but the resident?s name could not be clearly read as the bag was black and the name was written with a black marker.
Plan of Correction:	Executive Director provided medication aid with metallic sharpie on day of inspection to clearly label resident #9?s glucometer bag and labeled the glucometer. Weekly, medication aids will perform cart audits to ensure single-use and dedicated medical supplies are labeled properly.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by standards on the MAR. Evidence: 1. Resident #3?s November 2023 MAR did not contain the diagnosis, condition, or specific indications for Furosemide 20 mg, Loratadine 10 mg, and the Serevent Diskus inhaler. Resident #4?s November 2023 MAR did not contain the diagnosis, condition, or specific indications for the Carvedilol 12.5 mg or the Albuterol solution. Resident #7?s November 2023 MAR did not contain the diagnosis, condition, or specific indication for the Ipratropium Brom 0.03% nasal spray, Latanoprost 0.005% eye drop, or the Vitamin D2 2,000 Unit soft gel. Resident #8?s November 2023 MAR did not contain the diagnosis, condition, or specific indication for the Lidocaine pain relief patch, Potassium 2o MEQ, Pro-stat Liquid, and Loperamide HCL 2mg capsule. 2. Resident #2 was administered PRN Claritin on 11/2/23, 11/10/23, 11/18/23, and 12/4/23. There was no documentation of the medication?s effectiveness on the MAR. Resident #7 was administered PRN Tramadol 50 mg on 12/1/23, 12/2/23, 12/3/23, 12/4/23, and 12/6/23. There was no documentation of the medication?s effectiveness on the MAR. 3. Resident #4?s November 2023 MAR did not record if the resident?s prescribed Gabapentin 300 mg was administered on11/22/23. There was no response recorded on the electronic MAR to explain the missing initials. Resident #7?s November 2023 MAR did not record if the resident?s prescribed Amlodipine 5 mg was administered on 11/5/23. There was no response recorded on the electronic MAR.
Plan of Correction:	Director of Health Services and/or designee will not approve medications in the electronic record system from pharmacy unless medication has a diagnosis, condition, or specific indication. All medication aids are to document effectiveness of PRN medications on the MAR. Community worked with electronic record system to enable an alert to remind staff to document on the effectiveness. Going forward, the clinical team, Executive Director and Director of Operations audit the electronic MAR to ensure medication aids are documenting the effectiveness of PRN?s. In addition, every day the clinical team, Executive Director and Director of Operations review the previous day medication pass to ensure if medication aids are unable to pass a medication, that they are documenting the reason. To avoid missed medications, if a medication aid is unable to find a medication on the cart, they must call the Resident Care Coordinator, Memory Care Director or Director of Health Services. On 2/7/24, medication aids received an in-service on this process and there are notes on every med cart to remind staff.