VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Williamsburg Campus
1807 Jamestown Road
Williamsburg, VA 23185
(757) 941-5099

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Nov. 30, 2021 and Dec. 8, 2021

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted on 11-30-21 (ar 08:11/dep 7:07 p.m.) The facility census was 12. A tour of the facility was conducted, resident and staff records and interviews were conducted, lunch meal was observed, medication pass observation was conducted, call bell and first aid kit checks were conducted, activity observed, water temperature checks observed and emergency preparedness reviewed. An exit meeting was conducted on 11-30-21 with administrator and staff. Requested documents received on 12-3-21. Final review and final exit meeting was conducted on 12-8-21 with the administrator. The acknowledgement form was presented during both exit meeting. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days: 12-18-21.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. On 11-30-21, resident #1?s assessment of serious cognitive impairment from the clinician dated 10-28-21, documented ?NO? to the question, ?Does the individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia?. The assessor documented ?NO? to the question, ?Is the individual named above unable to recognized danger or protect his/her own safety and welfare?. 2. The resident?s physical examinations dated 4-22-21 and 10-28-21 did not include documentation of dementia. 3. During the exit meeting on 11-30-21 and 12-8-21, staff acknowledged the assessor did not document dementia of the resident?s forms that were reviewed during the inspection on 11-30-21.
Plan of Correction:	The Administrator and Director Nursing will ensure that prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. 1. Facility notified PCP of Resident #1 and the provider completed a chart review for this resident. The provider updated assessment of serious cognitive impairment on 12/2/21. Updates to the assessment of serious cognitive impairment included a revision to answer "YES" to both aforementioned questions in regard to primary psychiatric diagnosis and inability to recognize danger or protect his/her own safety and welfare. DON and Administrator to review all assessments of serious cognitive impairments prior to admission in order to ensure that the appropriate documentation is provided for admission to a secure unit. 2. Facility requested a review of the History and Physical by PCP in order to address documentation of dementia diagnosis. Documentation of acute or chronic encephalopathy with dementia and TBP is documented on 11/12/21 in a summary from the hospital. Provider reviewed and revised H&P to add primary diagnosis of dementia on 12/2/21. DON and Administrator to review each H&P in order to ensure a primary diagnosis of dementia is listed prior to admission to a secure unit.
Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure it followed the blood glucose monitoring practices that are consistent with CDC recommendations. Evidence: 1. During the medication observation pass with staff #7, the glucometers for resident #4 and #5 were not labeled. 2. Staff #7 acknowledged the glucometers for the aforementioned residents were not labeled as required.
Plan of Correction:	The Director of Nursing and Administrator will ensure that blood glucose monitoring practices are consistent with CDC recommendations. 1. Glucometers for resident #4 and and #5 were labeled by an RMA, observed by the DON, on 12/10/21. DON or designated medication staff to ensure that each glucometer is appropriately labeled upon admission on upon new orders. Random audits of glucometers will be performed by the DON or designated medication staff, moving forward, in order to ensure blood glucose monitoring practices are consistent with CDC recommendations.
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the posted listing of staff certifications in first aid or CPR or both was kept up to date. Evidence: 1. On 11-30-21 during a tour of the facility with staff #1, the first aid and CPR posting included names of individuals no longer employed. 2. Staff #1 acknowledged the first and CPR posting was not kept up to date as required.
Plan of Correction:	The Administrator shall ensure all staff who have current certification in first aid or CPR are posted in the facility at all times. The listing shall indicate by staff person whether the certification is in first aid or CPR or both and will be current. 1.Administrator updated staff listing of first aid and CPR certifications on 12/1/21. Administrator or Designee will ensure that CPR/First Aid information is updated with each change of employee.
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the name of the current on-site person in charge was posted as required. Evidence: 1. On 11-30-21 upon arrival, the name of the staff person in charge posted was staff #1. Interview with staff #3 and #7, staff #1 had not yet arrived on the premises. The name of the current on site-person in charge was not posted. 2. Staff #1 acknowledged the posting of the current on-site person in charge was not posted.
Plan of Correction:	. The Administrator, Director of Nursing or designee will ensure that the name of the current on-site person in charge is posted in a place in the facility that is conspicuous to the residents and the public. 1. DON created a Daily Staff Person in Charge schedule and posted it on 12/1/21. DON, Administrator or Designee will ensure that posting is current, daily.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: 1. Resident #2?s record documented resident is prescribed Paroxetine. The record did not include documentation of a treatment plan for this psychotropic medication. 2. Resident #3?s record documented resident is prescribed Zyprexa and Risperidone. The record did not include documentation of a treatment plan for this psychotropic medication. 3. Staff #1 and #2 acknowledged the aforementioned resident?s record did not include a treatment plan for the prescribed psychotropic medication.
Plan of Correction:	The Administrator and Director of nursing will ensure that residents are not admitted or retained with conditions or care needs that do not coincide with VDSS regulations/standards. 1. DON reviewed psychotropic and PRN binder on 12/10/21 and located treatment plan for prescribed Paroxetine for resident #2. DON, Administrator or designated medication staff to conduct mostly reviews of psychotropic and PRN binder in order to ensure treatment plans for psychotropic medications without appropriate diagnosis are readily available. 2. Provider completed treatment plan for Zyprexa for resident #3 on 12/3/21. DON will coordinate with provider to complete treatment plan for Risperidone for resident #3 by 12/20/21. DON, Administrator or designated medication staff to conduct monthly reviews of psychotropic and PRN binder in order to ensure treatment plans for psychotropic medications without appropriate diagnosis are readily available.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs. Evidence: 1. Resident #2 was observed participating in physical therapy services on 11-30-21 with home health services. This service need was not documented on the resident?s Individualized service plan (ISP) dated 5-11-21. 2. Resident #3?s uniformed assessment instrument (UAI) dated 10-27-21 documented walking, bathing and toileting need as mechanical help/physical assistance. The ISP did not document what mechanical assistance was needed. The resident?s UAI documented bowel and bladder need less than weekly; the ISP documented the resident was continent for bowel and bladder. Wandering assessed as weekly or more, this need was not care planned on the ISP dated 11-5-21. Resident #3?s allergies to sulfa and latex was not completely care planned on the ISP. The resident?s physician order sheet dated 11-3-21 documented resident?s feet to be elevated and Ted hose to be on every morning; these assessed needs were not documented on the ISP. 3. Staff #2 acknowledged the aforementioned residents? ISP were not updated to reflect all assessed needs.
Plan of Correction:	The Director of Nursing, Administrator or Designee will ensure that each individualized service plan is completed in its entirety to include all areas as required by regulation. 1. DON will add physical therapy services to the ISP of Resident #2 by 12/13/21. DON, Administrator or designee will conduct random audits of ISPs monthly for 3 months and as needed moving forward in order to ensure compliance. 2. DON will update the ISP of Resident #3 to reflect the type of mechanical assistance needed to coincide with the UAI. UAI will be corrected and updated to reflect the needs in regard to bowel and bladder. ISP will be updated to address wandering as reflected on the UAI. ISP will be updated to include allergies and reactions to documented allergies. ISP will be updated to reflect physician's order in regard to feet elevation and Ted hose. All corrections/updates in regard to Resident #3 to be completed by 12/13/21. DON, Administrator or designee will conduct random audits of individualized service plans monthly for 3 months and as needed moving forward in order to ensure compliance.
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of resident was met. Evidence: 1. Resident #2?s record included an order for physical therapy and occupational therapy dated 9-2-21 and 10-6-21. 2. On 11-30-21, resident?s record did not document occupational therapy evaluation for services. 3. Staff #2 stated not being aware if occupational services were being provided.
Plan of Correction:	The Director of Nursing and Administrator will ensure that either directly or indirectly, the health care service needs of residents are met. 1. DON, upon chart review on 12/10/21, located OT evaluation in Resident #2's medical chart, dated 9/23/21. DON, upon chart review on 12/20/21, located PT evaluation in Resident #2's medical chart, dated 11/21/21. Director of Nursing, Administrator or Designee to ensure that PT/OT service documentation is readily available in the medical chart.
Standard #:	22VAC40-73-650-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber's orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include all of the required information. Evidence: 1. Resident #2's physician's order dated 11-8-21 did not include a diagnosis for Paroxetine. 2. Staff #1 and #2 acknowledged the order did not include a diagnosis and required.
Plan of Correction:	The Director of Nursing or designated Medication Staff to ensure that physician or other prescriber orders are complete to include diagnosis. 1. Provider updated physician's order to include diagnosis for Paroxetine on 12/2/21. Director of Nursing or designated Medication Staff will complete medication orders audits at random in order to ensure orders are complete to include diagnosis.
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all of the required information. Evidence: 1. During the medication observation pass with staff #7, resident #1's November 2021 medication administration record (MAR) did not include a diagnosis for Mucinex and Vitamin D3. 2. Staff #7 acknowledged resident #1's MAR did not include the required diagnosis for the aforementioned medications.
Plan of Correction:	The Director of Nursing or designated Medication Staff to ensure that the MAR includes diagnosis, condition, or specific indications for administering the prescribed drug or supplement. 1. Provider updated physician's order to include diagnosis for Mucinex and Vitamin D3 on 12/2/21 and DON added the diagnosis for Mucinex and Vitamin D3 to the MAR. DON or designated Medication Staff to complete MAR audits at random in order to ensure diagnosis are present.