VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Abingdon Campus
15089 Harmony Hills Lane
Abingdon, VA 24211
(276) 619-4572

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Sept. 19, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/19/2022 Start: 9:10am-conclude 4:20pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 14 Number of staff records reviewed: 16 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 he 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 Crystal B. Mullins Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-380-A
Description:	Based on the review of resident records, the facility failed to obtain all personal and social information prior to or at the time of admission for one resident. EVIDENCE: 1. Resident #1 was admitted to the facility on 06/30/2022. The personal and social data sheet was blank in the following areas: Date of Birth, on page 2 the personal physician, personal dentist, local department of social services and other agency as well current behavioral and social functioning, strengths and problems.
Plan of Correction:	Resident social data form was completed prior to exit meeting. Administrator/designee was inserviced on 9/21/2022 in regards to completion of the personal and social information form. Administrator/designee to perform audit of social data forms at random once per month for 3 months to ensure completion of personal and social information on social data form. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include all identified needs. EVIDENCE: 1. The record for Resident #4 contained signed orders, dated 08/16/2022, which indicate the following: ?O2 @ 2L concentrator given via nasal cannula for O2 stat less than 85% or gasping for breath, wheezing, nasal flaring, complaints of dyspnea, as needed.? 2. The ISP for Resident #4, dated 06/02/2022, does not indicate the resident?s need for oxygen as ordered. 3. The record for Resident #3 contained signed physician?s orders, dated 06/22/2022, which indicate the following: ?OXYGEN AT 2L/MIN VIA NASAL CANULA VIA CONCENTRATOR CONTINUOUS D/T HYPOXIA RESPIRATORY FAILURE?. 4. The ISP for Resident #3, dated 06/03/2022, states ?Resident to receive oxygen from provider of choice as ordered?; however, the ISP does not specify the ordered oxygen source, the delivery device, nor the therapeutic flow rate.
Plan of Correction:	All ISP certified staff inserviced by 9/23/22 to include ordered oxygen source, delivery device and therapeutic flow rate for resident on ISP when there is an order for oxygen. Administrator/DON/Designee to perform ISP audit for individuals at random receiving oxygen once per month at random for 3 months to ensure source, delivery device and therapeutic flow rate are included on ISPs. [sic]
Standard #:	22VAC40-73-550-G
Description:	Based on record review the facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident?s record. EVIDENCE: 1. The record for Resident #3 contained a most recent resident rights review signed 06/03/2021. 2. Interview with Staff #2 indicated that the 2022 review had occurred; however, it could not be located.
Plan of Correction:	Annual review of resident rights was located by Administrator on 9/20/2022. Administrator/Designee inserviced on 9/21/2022 in regards to annual review of resident rights. Administrator/Designee to perform resident rights audit at random once per month at random for 3 months and intermittently going forward to ensure resident rights is reviewed annually with resident. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. EVIDENCE: 1. The facility?s Medication Management Plan which was provided on the date of inspection states the following: ?During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going medication persons both sign off on the accurate counts of all narcotics on the Narcotic Administration Record?. 2. While performing an audit of the 2nd floor medication cart A at approximately 11:45 AM on the date of inspection 09/19/2022, the LI observed the narcotic count book was not completed and signed by oncoming and off-going medication staff on 9/7/2022 for the 7p ? 7a shift, nor was it completed on 9/8/2022 for the 7a ? 7p and 7p ? 7a shifts.
Plan of Correction:	All medication staff inserviced by 9/30/2022 in regards to ongoing and offgoing medication persons signing on the accurate counts of all narcotics on the Narcotic Administration record. DON/designee to perform Narcotic Administration record audits at random per week for 3 months and once per month at random for 3 months to ensure accurate completion of the Narcotic Administration record. [sic]