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: April 19, 2023

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 GROUND 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 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:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/19/2023 9:45AM through 12:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the center at the beginning of the inspection: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 3 Number of staff records reviewed: 3 Observations by licensing inspector: activities 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-220-C
Description:	Based on participant record review and staff interview, the center failed to address a need on a participant assessment. EVIDENCE: 1. The Plan of Care (POC), dated 03/06/2023, for participant 2 indicates that the participant may need assistance with cleaning when toileting; however, participant 2?s assessment, dated 03/06/2023, does not indicate this assistance. Interview with staff 2 indicated that the POC is correct and that the assessment should include this information.
Plan of Correction:	Nursing staff at Edwards will review and correct regulation violations to ensure the Plan of Care and Participant Assessments meet the state standards in the future. Date to be corrected: May 31, 2023
Standard #:	22VAC40-61-230-D
Description:	Based on participant record review and staff interview, the center failed to address a need and service provided by the center on a Plan of Care (POC) for a participant. EVIDENCE: 1. The participant assessment (PA) for participant 1, updated 02/02/2023, indicates that the participant requires minimal assistance (MA) with eating and feeding; however, the POC for the participant, updated 02/02/2023, indicates that the participant is independent in eating. 2. Interview with staff 2 revealed that the participate requires their food to sometimes be cut up depending on what the food is; therefore, the POC should include this information.
Plan of Correction:	Nursing staff at Edwards will review and correct regulation violations to ensure the Plan of Care and Participant Assessments meet the state standards in the future. Date to be corrected: May 31, 2023
Standard #:	22VAC40-61-460-H
Description:	Based on observation during a tour of the center, the center failed to ensure hot water taps available to participants were maintained within a temperature range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. EVIDENCE: The hot water from the sink in restroom number one measured 73.9 degrees Fahrenheit and the hot water from the sink in restroom number four measured 147 degrees Fahrenheit. This was also noted by staff 1.
Plan of Correction:	Edwards will have their Maintenance/Plumber take a look at the water heater and its lines to each restroom to address the problem. Afterwards, staff members will routinely check the water temperatures to ensure compliance. Date to be corrected: May 31, 2023