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: Aug. 6, 2024

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: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/06/2024 11:00AM until 1:00PM 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2 Number of staff records reviewed: 2 Observations by licensing inspector: medication administration, noon-time meal 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 #:	22VAC40-61-230-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: The participant assessment (PA) for participant 1, dated 07/02/2024, indicates that the participant has identified needs of complex decision making, language problems and reasoning and judgement; however, the POC for the participant, dated 07/02/2024, does not include these identified needs.
Plan of Correction:	EADC's Nursing staff will compare and mirror all Plan of Care and Assessments.
Standard #:	22VAC40-61-260-C
Description:	Based on participant record review, the center failed to ensure the subsequent medical evaluation for a participant contained all required components. EVIDENCE: The report of physical examination for participant 2, dated 02/21/2024, indicates that the participant is allergic to bee venom, red meat, and poison oak; however, there are no reactions listed for the allergies. This was also noted by staff person 1.
Plan of Correction:	EADC's Nursing staff will highlight any missed sections on the participants Physical to also include Allergies and Reactions and re-send to physician for clarification.
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 123.6 degrees Fahrenheit, restroom number two measured 124 degrees Fahrenheit, restroom number three measured 125.7 degrees Fahrenheit and restroom number four measured 134 degrees Fahrenheit. This was also noted by staff 1.
Plan of Correction:	EADC's Maintenance and Inventory Coordinator will check the hot water temperature in each restroom monthly. If temperatures are above regulations the hot water heater will be adjusted accordingly.
Standard #:	22VAC40-61-550-C
Description:	Based on observation, the center failed to ensure contents in a first aid kit shall be replaced before expiration dates and as necessary. EVIDENCE: During on-site inspection, it was noted by the licensing inspector (LI) and staff person 1 that the antibacterial ointment and bee sting preparation located in the first aid kit on bus 1 were both expired.
Plan of Correction:	EADC's Maintenance and Inventory Coordinator will conduct a monthly check on each first aid kit to ensure all items and expirations are current.