VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Edgeworth Park at New Town
5501 Discovery Park Boulevard
Williamsburg, VA 23188
(757) 345-5005

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: May 2, 2024 and May 9, 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/2/24 8:00 am- 5:00 pm, 5/9/2024 10:47 am - 4:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 16 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 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 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed by one of the following qualified assessors: An assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI. Evidence: The UAIs for Resident #7 (dated 4/23/2024), Resident # 16 (dated 3/7/2024), Resident #14 (dated 4/23/2024) did not contain the administrator?s nor administrator?s designee signature.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on records reviewed and staff interviews, the facility failed to develop Individualized Service Plans (ISPs) which contains all of the elements in 22VAC40-73-450-C. Evidence: The ISPs for Residents #8, #7, #16, #11, #13, #14, and #15 do not contain all of required elements of the ISP as listed in 22VAC40-73-450-C.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and interview with staff, the facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or his legal representative. Evidence: The ISPs for Residents #13 (dated 4/29/2024), Resident #11 (dated 11/10/2023), Resident #8 (dated 4/10/2024), and Resident #15 (dated 4/23/2024) did not contain a signature resident of the resident or his legal representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified. Evidence: 1. Resident # 14 is receiving hospice services. Those services are not on the resident?s ISP dated 4/23/2024. 2. Resident #13 is receiving podiatry services. Those services are not on the resident?s ISP dated 4/29/2024. 3. Resident #11 is receiving hospice and podiatry services. Those services are not on the resident?s ISP dated 11/10/2023. 4. Resident #8 is receiving hospice services. Those services are not on the ISP dated 4/10/2024.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-C
Description:	Based on documents reviewed and staff interviewed, the facility to ensure medications shall be administered not earlier than one hour before and not later than on hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: During the on-site inspection, Staff #5 was observed administering 8am medications at 9:50 am. A further review of the electronic medication administration record verified an additional 15 residents still needed to be administered 8 am and 9 am medication.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident and facility records, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions. Evidence: During the observation of the medication pass, the licensing inspector observed Staff # 5 administer Risperidone 0.25 mg in a medication cup with the resident?s other 8am medication. The physician?s orders for the Risperidone state the medication is to be dissolved on top of the tongue. The licensing inspector observed the resident swallow the pill.
Plan of Correction:	Not available online. Contact Inspector for more information.