VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Crozet Campus
1220 Crozet Avenue
Crozet, VA 22932
(540) 810-6200

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: May 17, 2019 and May 22, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Technical Assistance was provided to the facility regarding choice of beverage.

Comments:

Two Representatives with the Division of Licensing conducted an unannounced, mandated, monitoring inspection on 05/17/2019 from 4:00pm to 6:30pm and returned on 05/22/2019 from 11:08am to 2:25pm to complete the inspection. During the Licensing Inspector the facility Administrator was available and present. Upon entrance of the facility there were 68 residents in care. The Licensing Representatives reviewed 10 resident records and 5 staff records. The Licensing Representatives conducted a tour of the facility physical plant, observed residents during meals and activities, observed the facility medication and ministration records and reviewed addition facility records to access areas of non-compliance. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact the facility Licensing Inspector Kimberly Rodriguez at 804-662-9787 or by e-mail at kimberly.rodriguez@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1180-B
Description:	Based on observation of the facility physical plant, the facility failed to ensure when there are indications that ordinary material or objects may be harmful to a resident these material or objects are inaccessible to the resident except under staff supervision. Evidence #1: On 5/22/2019 with two licensing representatives present, it was observed that the facility secured unit's "Quiet Room" was unlocked and contained excess furniture including unsecured mirrors and a wheelchair, as evidenced by the photos taken. Evidence #2: On 05/17/2019, with two licensing representatives and staff #1 present, it was observed that the facility's sixth floor was under renovation. When licensing representatives arrived to the sixth floor no staff was present. The sixth floor was accessible to residents and contained items that may be harmful to residents including construction supplies, cleaning supplies, and medical supplies as evidenced by photos taken.
Plan of Correction:	Furniture has been removed from Quiet room. 6th floor has been securely locked down so that residents cannot access the floor. To Prevent: A Reminder will be put out to all staff members that all hazardous areas must be locked at all times when not supervised by a staff members, including tools, cleaning supplies and medical supplies.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review the facility failed to ensure staff received verification that the staff person has received a copy of his current job description. Evidence: On 5/22/2019, with two licensing representatives and staff #1 and #2 present, staff #3, #4, #5, and #6 did not have verification of receiving a copy of the staff's current job description in their staff records.
Plan of Correction:	English Meadows has created a new form for staff members to document what forms they have received during new hire process. We will make sure all current staff receive copies and sign the new form by 6/20/19. To Prevent: New Form with list of all documents received has been created and added to new hire paperwork.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: On 05/22/2019 with two Licensing Representatives and staff #1 and #2 present, the First Aid certification completed on 04/27/2018 in staff's #5's record was not provided by an approved vendor.
Plan of Correction:	Staff #5 will attend CPR/ 1st Aid on 6/18/19 through American Red Cross. To Prevent: Assistant Administrator will audit all current staff members and all new hires going forward to make sure they have an approved certification
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure the comprehensive individualized service plan contained a written description of what services will be provided to address identified needs. Evidence #1: On 5/17/2019 with two licensing representatives and staff #1 present, it was observed that resident #1 attempted to pinch a residing during meal time that was sitting on resident #1's right side. When resident #1 was finished the meal one licensing representative present observed resident #1 walking through the secure unit with a knife and fork in his hand pointed outward. Resident #1 stopped in front of the licensing representative present with the knife and fork pointed towards the licensing representative's stomach. Resident #1 turned and walked into resident #1's room, came out and returned to the dining area still holding the knife and forth pointing outward. Facility staff attempted to remove the knife and fork from resident #1's hand at the request of the licensing representative present. The resident became agitated and attempted to get more knives and forks off of the dining table. The resident then began removing desert from other resident's that were still eating in the dining area. Resident #1's Individualized Service Plan revised on 2/19/2019 has an identified need of "Behaviors-dementia" and included interventions of "exhibits inappropriate behavior: (Specify) disrobing, taking things belonging to others, wandering aimlessly, showing anger, provocation, verbal abuse or other extreme or erratic behavior patterns. Makes sexually inappropriate comments to women without malice. Socially inappropriate at times." The Individualized Service Plan did not address what services would be provided to address the identified needs.
Plan of Correction:	New Administrator, DON and ARCC have already began auditing all Care plans for residents, they will meet every Wednesday to complete care plans and make sure they address all needs and goals of residents. To prevent: Going forward the DON will keep an updated list of ISP due dates. DON and ARCC will make sure that all residents changes are addressed on the ISP.
Standard #:	22VAC40-73-450-D
Description:	Based on observation and review of the resident record, the facility failed to include on the individualized service plan the services to be provided by a hospice organization. Evidence : Resident #10 was admitted to hospice on 2/14/2019. The revised Individualized Service plan dated 3/7/2019 for resident #10 did not include the services to be provided by hospice.
Plan of Correction:	New Administrator, DON and ARCC have already began auditing all Care plans for residents, they will meet every Wednesday to complete care plans and make sure they address all needs and goals of residents. To prevent: Going forward the DON will keep an updated list of ISP due dates. DON and ARCC will make sure that all residents changes are addressed on the ISP.
Standard #:	22VAC40-73-680-D
Description:	Based on observation of the medication administration pass, the facility failed to administer medications consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence #1: On 05/17/2019 with two Licensing Representatives and staff #1 present, it was observed that staff #6 did not wash nor sanitize hands prior to or after administering medication to resident #1, #2, #3, or #5 as stated in Section 4.1, Section B, Number 12 " Identify Basic Guidelines for Administering Medication" that states "Practice aseptic technique. Wash hands before and after administering a medication." Evidence #2: On 05/17/2019 with one Licensing Representative and staff #1 , staff #6 was observed by Licensing Inspectors present and staff #1 administering an insulin injection of Humolog Solution 100u/ml in resident #3's stomach while the resident was sitting at the dining room table eating with other residents. Staff #6 did not provide the resident, with private location to receive medical treatment as stated in Section 1.2 Recognize the Implication of Clients Rights Regarding Medications, Treatment Decisions, and Confidentiality, Section A, Number 4 " Right to privacy during medical treatment including the administering of medications."
Plan of Correction:	Staff #6 will receive complete training on Medication Administration to include Hand washing, sanitizing hands, Resident rights regarding medications and confidentiality. All staff will take the Med Refresher course through our training system. To Prevent: DON will conduct monthly audits of Med passes and ensure that all med staff are audited at least quarterly to ensure compliance.
Standard #:	22VAC40-73-870-A
Description:	Based on observation of the facility physical plant the facility failed to ensure the interior was maintained in good repair. Evidence: On 05/17/2019 with two Licensing Representatives and Staff #1, it was observed that multiple ceiling tiles were stained as evidenced, by photos taken.
Plan of Correction:	Stained ceiling tiles will be replaced To Prevent: Maintenance Director will do monthly walk through of building and replace stained ceiling tiles.