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: June 15, 2022

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 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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/15/2022 10:15 AM ? 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 required 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based on record review, the facility failed to ensure that for a private pay individual, the uniform assessment instrument (UAI) is completed as required. EVIDENCE: 1. The UAI for resident 6, dated 12/01/2021, indicated that this resident requires supervision when bathing; however, the resident?s individualized service plan (ISP), dated 12/15/2021, indicated that the resident requires mechanical assistance and human supervision for bathing. In addition, the UAI for resident 6 indicated that this resident requires human physical assistance only while toileting; however, the ISP indicated that this resident requires mechanical and physical assistance for toileting. Also, the UAI for resident 6 indicated that this resident requires physical assistance for mobility; however, the ISP indicated that this resident requires mechanical and physical assistance. Finally, the UAI for resident 6 indicated that the resident requires supervision when walking; however, the ISP for this resident indicated that the resident requires mechanical assistance. 2. Interview with staff 6 indicated that for bathing, toileting, mobility, and walking, the UAI for resident 6 is incorrect. 3. The UAI for resident 8, dated 03/01/2022, indicated that the resident requires mechanical assistance for stairclimbing; however, the ISP for resident 8, dated 03/01/2022, indicated that the resident requires mechanical and physical assistance. 4. Interview with staff 6 indicated the UAI for resident 8 is incorrect.
Plan of Correction:	The DON and Administrator will review UAIs and ISPs to ensure documents are completed as required. The Director of Resident Care will audit 3 completed UAIs and ISPs monthly for 3 months.
Standard #:	22VAC40-73-550-G
Description:	Based on review of resident files, the facility failed to review the rights and responsibility with one resident on an annual basis. EVIDENCE: 1. Resident 3 was admitted to the facility on 07/07/2020. 2. Resident rights were documented as reviewed on 07/07/2020 and 01/04/2021. 3. The rights were not documented as reviewed again in the resident file.
Plan of Correction:	Resident 3?s Rights were reviewed and signed on 06/16/2022.
Standard #:	22VAC40-73-650-A
Description:	Based on record review, the facility failed to ensure that no medication shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. Resident 15 has a signed physician?s order for sliding scale insulin for Humalog Kwikpen 100 unit/mL injection, effective 06/03/2021, which indicates ?INJECT SUBCUTANEOUSLY PER SLIDING SCALE BEFORE MEALS AND AT BEDTIME FOR DM AS FOLLOWS; 250-299 =8U; 300-349 =10U, 350-399 = 12U, 400-449 = 14U, 450-499 = 18U, OVER 500 = 24U, IF ?HI? CONTACT MD/NP?. 2. Per a review of the June 2022 medication administration record for resident 15, documentation from medication administration staff indicates that Humalog Kwikpen 100 unit/mL injection was given incorrectly based on the sliding scale on the following dates and times: 06/01/2022 at 09:00 PM, blood glucose (BG) = 500, was given 14 U; 06/02/2022 at 04:30 PM, BG = 268, was given 0 U; 06/03/2022 at 06:30 AM, BG = 174, was given 13 U; 06/07/2022 at 09:00 PM, BG = 384, was given 14 U; 06/08/2022 at 06:30 AM, BG = 336, was given 0 U; and 06/13/2022 at 09:00 PM, BG =346, was given 120 U.
Plan of Correction:	All medication staff will receive additional review for sliding scale medications. DON will conduct random monthly audits for residents receiving sliding scale medications for 3 months.
Standard #:	22VAC40-73-700-1
Description:	Based on record review, the facility failed to ensure that oxygen orders contained the oxygen source, such as compressed gas or concentrators; the delivery device, such as nasal cannula, reservoir nasal cannulas, or masks; and the flow rate deemed therapeutic for the resident. EVIDENCE: The record for resident 8, admitted 02/21/2022, contained signed physician?s orders, effective 06/01/2022, that stated ?Continue home O2? with no other clarifying oxygen orders found in the resident?s record.
Plan of Correction:	The DON will review oxygen orders monthly to ensure accuracy and containment of source, delivery device and flow rate.
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean. EVIDENCE: 1. The door to the restroom and the door to the medication room at the entrance of the safe and secure unit had a brown and black substance or stain on the surface in an approximate three foot section. 2. The resident room doors had been painted blue, the blue paint is worn and scratched off from the surface leaving the under color of paint visible. The room numbers are: H101, 102, 103, 104, 105, 106, 107, 117, and 122 all in the safe, secure unit. 3. The dining area in the safe, secure unit near the exit to the outdoors was observed to have black scrapes, scratches, and scuffs all around the perimeter which appeared to be wheelchair level along the wall.
Plan of Correction:	The walls, resident room doors and dining area were in process of repair and touch up paint prior after areas were identified during a facilities self-audit, then again at inspection. Areas were completed 07-01-22.
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to keep all furnishings, fixtures, and equipment clean and in good repair. EVIDENCE: 1. The bottom cabinet area of the fish tank in the safe and secure unit had scratches and scrapes in the wood finish.
Plan of Correction:	The fish tank cabinet was noted to need repair during a facilities self-audit, and at inspection. Area was completed on 07-01-22.
Standard #:	22VAC40-73-980-A
Description:	Based on the audit of the first aid kit, the facility failed to include all items required by the standards in the first aid kit. EVIDENCE: 1. The first aid kit did not contain the required disposable single-use breathing barriers or shields for use with rescue breathing or CPR.
Plan of Correction:	The DON or designee will complete monthly audits for the first aid kit. The CPR barrier was replaced on 06-16-22.