VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Blacksburg Campus
3400 South Point Dr.
Blacksburg, VA 24060
(540) 317-3463

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-440-H
Description:	Based on documentation review, the facility failed to ensure Uniform Assessment Instruments (UAI) were completed on an annual basis for one resident in care. EVIDENCE: 1. The most recent private pay UAI provided to the LI on the day of inspection for resident # 1 was dated 06/26/2020. This is past the annual assessment date.
Plan of Correction:	Resident 1?s UAI was updated. The Facility will complete the UAI on an annual basis or as needed. The administrator will conduct 5 random UAI audits/month for 3 months to ensure compliance. [sic[
Standard #:	22VAC40-73-450-H
Description:	Based on documentation review of Individual Service Plans (ISPs), the facility failed to ensure the care and services specified in the ISP are provided to each resident. EVIDENCE: 1. According to the ISP for resident # 1 dated 7/12/2021 it is documented she needs assistance with medication administration and will receive all medications as prescribed by the doctor. According to the December 2021 Medication Administration Record resident # 1 did not receive five of her prescribed medications from December 7-31, 2021. 2. According to the ISP for resident # 1 dated 7/12/2021 it is documented she wears hearing aides and needs assistance putting them on in the mornings and making sure that the battery is working. The Licensing Inspector observed resident # 1 holding her hearing aides in their case at lunchtime on the day of inspection. Resident # 1 told the licensing inspector no one had helped her put them in.
Plan of Correction:	Resident 1 requests the community assist her with putting in hearing aids in the morning and at night. The facility placed a nursing measure on the EMAR which will require the medication staff to document assistance or declination of assistance in the EMAR. DON will conduct random HA audits at least 2x/wk, for 2 months to ensure compliance on Resident 1. [sic]
Standard #:	22VAC40-73-460-A
Description:	Based on documentation review and interviews with staff, the facility failed to assume general responsibility for the health, safety and well-being of one resident in care. EVIDENCE: 1. According to the most recent Uniform Assessment Instrument (UAI) for resident # 1 dated 06/26/2020 rates her dependent in medication administration. 2. According to the Individualized Service Plan (ISP) for resident # 1 dated 7/12/2021 it is documented she needs assistance with medication administration and will receive all medications as prescribed by the doctor. 3. According to the Physical Examination report for resident # 1 dated November 1, 2019 she has a diagnosis of congestive heart failure, hypertension and has a medical history of aspiration pneumonia. 4. According to the most recent physicians orders for resident # 1 dated December 7, 2021 she is prescribed the following medications: Ferrous Sulfate 325 mg tablets take one tablet by mouth once daily for supplement, Furosemide 20 mg tablets take one tablet by mouth once daily for congestive heart failure, Metoprolol Succinate 25 ext-release tablets take one tablet by mouth once daily for atrial fibrillation hold if systolic blood pressure is less than 120 and diastolic blood pressure is less than 75, Mytbetriq 25 ext-release tablets take one tablet by mouth once daily for stress incontinence, Spironolactone 25 mg tablet take one tablet by mouth once daily for edema. According to the Medication Administration Record (MAR) for resident # 1 she did not receive these five medications from December 7-31, 2021. According to the MAR the five medications listed above had been discontinued. There was no corresponding discontinue order. The Licensing inspector spoke with resident # 1?s prescribing physician and he confirmed these medications had not been discontinued. 5. According to a written statement submitted to the LI on 02/15/2022 from resident #1?s prescribing physician he reported missing these medications could have caused resident # 1 to have an exacerbation of congestive heart failure that potentially could have been lethal.
Plan of Correction:	The resident?s medications were reordered from the pharmacy on 12/6/21 with signed physicians? orders. EMAR privileges, at that time, did not permit medication staff to view expiration dates of orders. This has since been updated. The pharmacy did not send medications as reordered on 12/6/21 and medication staff were unable to see expired prescriptions. Medications were not knowingly withheld from the resident by the facility. The pharmacy has begun sending a routine report which shows upcoming expiration dates for medication orders so POs can be sought to continue or d/c medications. The DON will review expiring medication report weekly to ensure compliance. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on documentation review of the Medication Administration Record (MAR) and interviews with staff, the facility failed to ensure that a physician's order was obtained prior to stopping or changing one resident's medication and treatment. EVIDENCE: 1. The licensing office received a complaint on 01/03/2022 regarding resident # 1 not receiving her prescribed medications and her daily weights in accordance with physician?s orders. 2. According to the Physical Examination report for resident # 1 dated November 1, 2019 she has a diagnosis of congestive heart failure, hypertension and has a medical history of aspiration pneumonia. 3. According to the most recent physicians orders for resident # 1 dated December 7, 2021 she is prescribed the following medications: Ferrous Sulfate 325 mg tablets take one tablet by mouth once daily for supplement, Furosemide 20 mg tablets take one tablet by mouth once daily for congestive heart failure, Metoprolol Succinate 25 ext-release tablets take one tablet by mouth once daily for atrial fibrillation hold if systolic blood pressure is less than 120 and diastolic blood pressure is less than 75, Mytbetriq 25 ext-release tablets take one tablet by mouth once daily for stress incontinence, Spironolactone 25 mg tablet take one tablet by mouth once daily for edema. According to the Medication Administration Record (MAR) for resident # 1 she did not receive these five medications from December 7-31, 2021. According to the MAR the five medications listed above had been discontinued. There was no corresponding discontinue order by the physician. The Licensing inspector spoke with resident # 1?s prescribing physician on 01/14/2022 and he confirmed these medications had not been discontinued. 4. According to physicians orders dated 11/1/2019 resident # 1 is prescribed an additional treatment that daily weights are to be conducted. 5. According to physician?s orders dated 11/01/2019 and an interview with the administrator, resident # 1 is to be weighed daily. Resident # 1 was admitted to the hospital in November 2019 and returned from the hospital to the facility with the daily weight order still in place. According to the administrator the daily weights have not been maintained since November 2019.
Plan of Correction:	Daily weight orders were not on the signed physicians? orders for seven (7) cycles after a hospitalization in 2019. On 2/15/22, an order was written to discontinue the daily weight checks. The new order stated to start weekly weight checks, and to notify the PCP if there is a weight gain over 3 pounds. The facility will seek physicians? orders prior to stopping or changing orders. [sic]