VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Village at Woods Edge
1401 North High Street
Franklin, VA 23851
(757) 562-3100

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Dec. 30, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted by the Licensing Inspector from the Eastern Regional Office. The inspection was conducted on December 30, 2019 from 10:50 am until 2:45 pm. There were 31 residents in care. During the inspection a tour of the grounds surrounding the building was conducted. Resident and staff records were reviewed. There was a discussion regarding supervision of residents and private duty personnel. The facility received one violation in the area of Resident Care and Related Services. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Methods to prevent re-occurrence, and 3. Person(s) responsible for implementing each step and/or monitoring any preventive actions.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs such as wandering from the premises. Evidence: 1. Resident #1's nursing notes dated 12-14-19 at 10:45 am, documented that a staff observed the resident "at the hospital by the road". The resident was recovered near the hospital ER. Nursing notes documented that previous to this incident, the resident was attempting to get in a car with another resident that was leaving and stated she needed a ride south. Staff documented the resident was acting "suspicious". In addition, resident #1's nursing notes documented the following: a. On 6-24-19 the resident was found "wandering out on the IP parking lot". b. on 9-28-19 at approximately 10:30 am the resident was observed by staff in the parking lot, walking away from the facility stating she was going to see her son. Later that day at approximately 11:15 am the staff documented the resident was observed walking toward parked cars in the parking lot stating that her son was expecting her. c. On 9-29-19 the resident was observed asking several residents for a ride as they were leaving the facility and was documented as "agitated". d. On 9-30-19 the nursing notes documented the resident gets "very confused at times". 2. Resident's Uniform Assessment Instrument (UAI) dated 3-19-19 and the Individualized Service Plan (ISP) dated 7-30-19 documented resident needs supervision with mobility. The ISP documented "resident may go out and about from the facility with staff supervising her". 3. Staff #1 acknowledged the resident wandered from the assisted living without supervision, walking toward the hospital on the service road and acknowledged the aforementioned incidents where the resident displayed exit seeking behavior.
Plan of Correction:	The facility will communicate with the Power of Attorney (POA) or Designee to provide direct supervision of a resident with any recognition of "suspicious" activity with evidence of wandering tendencies to keep resident safe until further arrangements can be made, or during a 30 day letter of notice period, or where and extension has been granted. An investigation and documentation of the incident(s) will be recorded in resident's record, and will be provided during those "busy" or suspicious periods of the day where redirection /activity or 24 hour supervision shall be scheduled for safety. The care givers hired by the POA or Designee will understand resident needs and provide safety. The individualized service plan will reflect the residents current needs to protect the health and safety of the resident. The information will be documented in the resident's record. 9/20/19 30 Day Notice given for resident inappropriateness of being "busy" and interfering with other resident's daily activities while at meals/activities ( not wandering at the time until very unfortunate incident on 12/14/19). Resident needed a Medicaid bed at this time-and while waiting, resident had very much improved with medication management by physician/activity one on one schedules during day. Bi-Polar/Dementia-Resident had difficulty expressing herself with word finding. 10/20/19 -Extension given as no beds available at facilities family reviewed in immediate and surrounding areas, and son was in process of moving to Fairfax; daughter lives in Pennsylvania. Goal for Resident to move to Fairfax near son. Needed to find a Medicaid bed at this point, which was very difficult, even Nursing Home due to availability. Fairfax Facility Resident requirement was Day trials at the Assisted Living /Nursing Home facility-first trial, then had to wait two weeks before hearing anything after many calls; then Fairfax decided after that two weeks, they wanted another Day trial at their facility, then after another two weeks of waiting, resident was approved for non-secured environment Medicaid bed. 10/23-31/19-Resident had 24 hr sitter due to agitation of not sleeping one night-up during night and knocking on doors, but talked with physician and he adjusted her medication and she settled down. 12/14/19 Incident of elopment occurred at The Village-then had to wait for Medicaid secured bed. 24 hour sitters put into place with resident until discharge. 12/23/19- Was Corrected-Family came when they received the call that the Medicaid bed was available and the resident was discharged. Discharge Summary Complete.