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

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Aug. 27, 2019

Complaint Related: No

Areas Reviewed:
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 ACCOMODATIONS AND RELATED PROVISIONS
22VAC40-73 BUILDING AND GROUNDS
22VAC40-73 EMERGENCY PREPAREDNESS
22VAC40-90 The Sworn Statement or Affirmation
22VAC40-90 The Criminal History Record Report

Technical Assistance:
Recommendation was made for new key staff to attend Assisted Living Facility Phase II training at VDSS.

Comments:
An unannounced renewal inspection was conducted on 8/27/19 by 3 licensing inspectors from approximately 10:50 a.m. - 4:20 p.m. Previous violations were reviewed and corrected. Current census reported is 70. During the inspection, a tour of the facility was conducted, a sample of 10 resident and 5 staff records were reviewed, facility documentation was reviewed, medication pass observation was conducted, review of medication administration records and physician orders were reviewed, first aid kit supplies were reviewed, emergency food/water supplies were checked, menu and activity calendars were reviewed, lunch meal and activities were observed and interviews with staff and residents were conducted, with no concerns reported. All new personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance. An exit meeting was held with the administrator and the director of nursing. Violations were cited during this inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 days. 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 non-compliance 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 me via e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:
Standard #: 22VAC40-73-1100-A
Description: Based on review of resident records , the facility failed to obtain written approval prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment (SCU). Evidence: Resident #8 and Resident #9 both reside in the SCU and their records did not contain written proof of approval for placement in the SCU.

Plan of Correction: Administrator and Director of Nursing to ensure that written proof of approval for placement in the secure care unit will be received prior to admitting any residents in the secure care unit. Records will be audited by Administrator and Director of Nursing monthly to ensure compliance.

Standard #: 22VAC40-73-1110-B
Description: Based on review of resident records, the facility failed to ensure that six months after placement of the resident in the safe, secure environment (SCU) and annually thereafter, a review of the appropriateness be completed of each resident's continued residence in the SCU. Evidence: Resident #8, Resident #9 and Resident #10 are all residing in the facility's SCU and their records did not contain documented proof that a current review of appropriateness was completed.

Plan of Correction: Administrator will ensure that the review of appropriateness for all residents in the secure unit will be completed 6 months following the initial date of placement in the secure unit and annually thereafter. Records will be audited monthly by Administrator to ensure compliance.

Standard #: 22VAC40-73-250-D
Description: Based on review of staff records and facility documentation, the facility failed to ensure that each newly hired staff person on or within seven days prior to the first day of work at the facility or subsequently, each staff annually submit the results of a tuberculosis (TB) risk assessment and documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1) Staff #3 (date of hire 2/1/19) documentation of TB risk assessment was dated 2/5/19, which is after the date of hire. 2) Staff #4 documentation of TB risk assessment was dated 4/20/18, which is not currently within this annual period.

Plan of Correction: Assistant Administrator and Administrator to ensure that all tuberculosis (TB) risk assessments are done upon hire. Administrator and Assistant Administrator to audit records to ensure completion at least 7 days prior to hire date and annually from date of hire.

Standard #: 22VAC40-73-440-H
Description: Based on review of resident records, the facility failed to ensure that an annual reassessment be utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: The most current reassessment completed for resident #5 was dated 2/6/18, which is not currently within this annual reassessment period.

Plan of Correction: Director of Nursing and Administrator to ensure that all reassessments are to be completed annually and upon any significant change. Director of Nursing and Administrator will audit resident records monthly to ensure compliance.

Standard #: 22VAC40-73-450-E
Description: Based on review of resident records and facility documentation, the facility failed to ensure that the individualized service plan (ISP) be signed and dated by the resident or the legal representative. Evidence: 1) During the inspection, the facility was not able to provide signature pages of ISP's for Resident #5 (ISP dated 6/5/19), Resident #6 (ISP dated 8/20/19), Resident#7 (ISP dated 8/28/19), Resident #8 (ISP dated 8/21/18), Resident #9 (ISP dated 8/21/18) and Resident #10 (ISP dated 9/30/19), to show documentation that the ISP's were signed and dated by the resident or the legal representative.

Plan of Correction: Director of Nursing and Administrator to ensure that all completed Individualized Service Plans are signed by the resident or legal representative. Director of Nursing and Administrator to audit resident records monthly to ensure completed ISP signature pages are received. If signature pages are not received in a timely manner, documentation will be provided regarding the actions the facility takes to get it signed by the resident or legal representative.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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