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: Sept. 13, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 09/13/2023 from 8:45 am to 5:00 pm. The Acknowledgement of Inspection form was signed and left at the facility. Number of residents present at the facility at the beginning of the inspection: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: emergency preparedness drills, resident fire and resident emergency drills, medication plan, medication carts, fire inspection report, health inspection report, a staffing schedule, and the water temperature was measured. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757-353-0430) or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on the record review the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons: the resident, guardian, legal representative, or an independent physician. Evidence: 1. Resident # 3 record includes an admission date of 01/06/23 into the safe, secure unit. During the record review on 09/13/23, the record did not include documentation of a written approval of placement in the safe secure environment signed by the resident, guardian, legal representative, or relative. 2. Staff #5 acknowledged during the time of the record review, the record for resident #3 did not include a written approval for placement in the safe, secure unit signed by the resident, guardian, legal representative, or relative. After the record review, staff #5 received via email on 09/13/23 the signed written approval from the relative of resident #3, however the facility did not provide evidence the written approval signed by the relative was obtained prior to the resident?s admission into the safe, secure environment.
Plan of Correction:	1. The facility failed to ensure paperwork for prior approval by resident, guardian, legal representative, or an independent physician for resident #3 in secured environment before admission. Resident power of attorney (POA) was contacted, resident POA lives out of state and had failed to remit the signed documents and facility overlooked documents were not received. POA had signed documents in computer system and forwarded the documents via email to the facility and documents placed in resident record before inspection complete.
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident. Evidence: 1. The record for resident #3 contains a risk assessment for TB dated 03/28/22. The record does not contain documentation of a risk assessment for TB completed annually after 03/28/22.
Plan of Correction:	The facility failed to ensure a risk assessment for TB was completed annually. The facility will ensure that the TB risk assessments are performed timely and annually for each resident. Resident #3 missing the TB risk assessment has an assessment scheduled with the Franklin health department on September 27th, 2023.
Standard #:	22VAC40-73-550-G
Description:	Based on the staff record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible party. Evidence: 1. The record for resident #4 contains an annual review of rights and responsibilities dated 03/23/22. The resident?s record does not contain an annual review of rights and responsibilities completed after 03/23/22
Plan of Correction:	Facility failed to ensure the annual resident rights and responsibilities of resident #4 was completed. The resident rights and responsibilities scheduled for review with resident and resident power of attorney by September 22, 2023.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked. Evidence: 1. During the medication pass observation in the safe, secure unit with staff #1, the LI observed staff # 1 leave the medication cart unattended and unlocked from 10:04 am- 10:07 am. Staff # 1 left the medication cart unattended and unlocked while placing hearing aids in the ear of resident #5. Staff #1 then proceeded to enter a storage room while the medication cart was unattended and unlocked. 2. During observation of the assisted living unit with staff #5, the medication cart on the 1st floor was observed to be unlocked and unattended by staff. The medication cart was assigned to staff # 2.
Plan of Correction:	1.The facility during a medication pass observation in the safe, secure unit with staff #1 failed to leave the medication cart locked while stepping away from cart. The cart was secured after staff #1 was prompted at that time and staff #1 was re-educated by Director on the policy procedures and safety importance of a secured medication cart. Date of Correction: September 13, 2023 2.While unlocked, the assisted living staff #2 left the medication cart unattended. The medication cart was locked during the walk through by the inspector. The facility Assisted Living Director re-educated staff #2 on the policy procedures and safety importance of a secured medication cart. Date of Correction: September 13, 2023, also all staff were re-educated on policy for secured medication cart when unattended on assisted living staff meeting on September 19, 2023. Policy sent to all Medication Aides, LPN, RN for review by September 22, 2023
Standard #:	22VAC40-73-660-B
Description:	Based on observation, resident and staff interviews the facility failed to ensure residents may be permitted to keep his own medication in an out-of-sight place if the Uniform Assessment Instrument (UAI) indicates that the resident is capable of self-administering medication. Evidence: 1. During the medication pass observation with staff #1. The Licensing Inspector, LI observed an over-the-counter medication ?Natural Ears? on a table in resident?s #4 room. Resident #4 confirmed self-administering the over-the-counter medication because of experiencing ?ringing in the ears.? Staff #1 confirmed resident #4 did not have a physician order for the over-the-counter medication, ?Natural Ears.? 2. The record for resident #4 does not contain a physician order for ?Natural Ears? or an order for self-administration of medications. 3. Resident?s #4 UAI dated 03/27/23 documents the resident?s medications are to be administered/monitored by a RMA/LPN and the UAI does not include documentation the resident is capable of self-administering medications.
Plan of Correction:	The facility failed to ensure resident #4 may be permitted to keep their own over-the-counter medication in an out-of-sight place, resident did not have and order for the over-the-counter medication, and the resident UAI stated resident #4 could not self-administer medications. The facility removed the over-the-counter medication that the family brought into #4 apartment the day before. Reviewed once again the policy and regulation for over-the-counter medications and storage procedures with the family member (POA) on September 19, 2023.
Standard #:	22VAC40-73-980-H
Description:	Based on the onsite observation the facility failed to ensure availability of a 96-hour supply of emergency food and drinking water. Evidence: 1. The emergency drinking water reviewed onsite with staff #5 included cases of 1 Gallon jugs of water with expiration dates of 03/31/23, 05/31/23, and 08/31/23. During the review, the facility did not have an available supply of emergency drinking water for the current census of 48 residents.
Plan of Correction:	1.Expired emergency drinking water. A few gallon jugs of drinking water were supplied on 9/13/23 before inspection complete and a full order was placed on 9/13/23 before inspection complete. The in-date water arrived on 9/15/23 and was placed in the emergency storage area on 1st and 2nd floor for 48 residents. The Dining Director has on calendar re-order date of drinking water before expiry date of current water which is 8/2024.