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: March 13, 2024

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced monitoring inspection took place on 03/13/2024 from 10:39 am am to 12:12 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (self-reported incident) was received by VDSS Division of Licensing on (02/02/2024) regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the assisted living and safe, secure environment was completed. 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 #:	22VAC40-73-110-1
Description:	Based on the onsite record review the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled. Evidence: 1. The record for staff #1 contains three written statements completed by facility staff that include reports of staff #1 being verbally and physically abusive to residents. 2. The facility?s incident report dated 02/02/24 includes the following documentation: ?3 staff members very concerned about staff #1 actions with residents. The documentation mentions multiple residents and specific residents of physical and verbal abuse.? 3. The record for staff #1 contains a termination date of 02/02/24 and the reason to include: ?subjected residents to physical and verbal abuse.?
Plan of Correction:	The Village at Woods Edge will re-educate staff on Resident Rights and Responsibilities (Be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled). The Village will re-educate all Assisted Living- Manor and Asa's Neighborhood staff so that if they witness verbal or physical abuse to any resident the incident shall be reported to their supervisor immediately.
Standard #:	22VAC40-73-660-A
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 a tour of the facility @ 10:54 am, the medication cart located on the first floor was observed to be unlocked and unstaffed.
Plan of Correction:	The Village at Woods Edge will re-educate staff#2 and all Assisted Living- Manor and Asa's Neighborhood of the storage of medications.