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: Sept. 20, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/20/2022 Begin: 3:55pm Conclude: 5:18 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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. 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 #:	22VAC40-73-930-A
Complaint related:	Yes
Description:	Based on a review of three of the resident signaling and call system logs, the facility failed to respond timely when direct care staff was notified when a resident needs assistance. 1. The call system log was reviewed for three pendants from the date range of 09/13/2022-09/21/2022. According to an interview with Staff #1 and Staff #2, they both agreed a 15 minute response time is an appropriate time frame. 2. Pendant 244 requested assistance on four occasions in which more than 30 minutes passed before a direct care staff member responded to the resident?s need. The following dates, times, and response times were documented for pendant 244: 9/18/22 10:55pm 39:10 9/19/22 10:26pm 1:02:05 9/19/22 11:50pm 31:28 9/20/22 12:33am 1:05:00 3. Pendant 130 requested assistance on two occasions in which more than 30 minutes passed before a direct care staff member responded to the resident?s need. The following dates, times, and response times were documented for pendant 130: 9/17/22 5:15am 1:10:28 9/17/22 12:46pm 38:15 4. Pendant 203 did not have any occasions in which more than 30 minutes passed before a direct care staff member responded to the resident?s need.
Plan of Correction:	Administrator initiated facility Call Light System review for upgrade prior to inspection. Call Light System upgrade service date pending. Nursing Department provided instruction on Call Light Response Time by Administrator on 9/21/22. [sic]