VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Edwards Adult Day Center
431 East Commonwealth Blvd
Martinsville, VA 24112
(276) 666-9400

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: March 28, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS. 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2(19.2) Criminal Procedures. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

On 3/28/2022 one inspector conducted a mandated monitoring visit (11:40 AM to 2 PM). 34 participants were in care with seven direct care staff with them. Three participant, three staff records, and other documents were reviewed. The participants were observed in activities and a meal. A physical plant tour was done. An exit meeting was held on-site the day of the inspection, and the facility was given an opportunity to provide additional evidence. A final telephone exit interview was done on 4/14/2022.

Violations:

Standard #:	22VAC40-61-230-D
Description:	Based on participant record review, the facility failed to include some needs and services on a plan of care. EVIDENCE: 1. A uniform assessment instrument in the file for participant 1 dated 10/4/2021 shows this person needs help with bladder incontinence - weekly or more, transferring - Human Help Supervision, and toileting, Human Help Supervision. The plan of care for participant 1 dated 10/11/2021 does not identify nor address these needs.
Plan of Correction:	The Virginia Private Pay UAI will be utilized for every participant prior to admission and annually. The identified needs will be implemented on the participant's Plan of Care.
Standard #:	22VAC40-61-250-B
Description:	Based on participant record review, the facility failed to obtain some required personal information. EVIDENCE: 1. The records for participants 1, 2, and 3 lacked information concerning mental health, substance abuse, or behavioral concerns. 2. The record for participant 2 lacked a photograph or narrative physical description of the participant.
Plan of Correction:	Participant Record will be revised to cover all information within the VDSS standard.
Standard #:	22VAC40-61-260-A
Description:	Based on participant record review, the facility failed to obtain a physical examination for a participant with in 30 days prior to admission. EVIDENCE: 1.. Participant 2 was admitted on 3/22/2022. The physical examination was dated 2/14/2022.
Plan of Correction:	Facility will use an admission checklist to ensure physical and admission dates follow VDSS standards.