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: Nov. 4, 2022

Complaint Related: Yes

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: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/04/2022 Begin: 11:00am End: 1:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Use this statement only if the inspection is related to a complaint or self-reported incident: A complaint was received by VDSS Division of Licensing on 10/12/2022, 10/13/2022, 10/15/2022, 10/17/2022 and 10/25/2022 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations of non-compliance with standard(s) or law. A violation notice was issued; any violation(s) not related to the (complaint(s) but identified during the course of the investigation can also 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. he 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. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on observations of the October and November 2022 MAR, the facility failed to ensure the MAR included all medications ordered by a physician. EVIDENCE: 1. Resident #1 was prescribed Acetaminophen 650 suppository on the physician?s order dated for 08/25/2022. This medication was not listed on the MAR.
Plan of Correction:	DON will do random MAR to POC audits X 3 months to ensure all orders are on the MAR. DON will do random audits thereafter to ensure compliance. Corrected date 11/11/22 [sic]
Standard #:	22VAC40-73-680-M
Complaint related:	No
Description:	Based staff interview, the facility did not have all PRN medications available for one resident. EVIDENCE: 1. Resident #1 was prescribed Calmoseptine Ointment, apply topically four times daily as needed for wound care and Metronidazole 0.75% cream, use as needed on lesion on wound on back. Neither of these medications were available to the resident at the time of this inspection on 11/04/22. 2. Staff #3 stated the above mentioned medications were not on the medication cart in the facility.
Plan of Correction:	Administrator and/or DON will audit call light log weekly to ensure timely answering of call lights X 3 months. Staff re-educated regarding timely response to all call lights. Administrator and/or DON will continue to conduct random call light audits to ensure continued compliance. Corrected date 11/15/22 [sic] DON will audit Med carts 2 X a month X 3 months to ensure all PRNs are available. DON will thereafter complete random audits to ensure continued compliance. Corrected date 11/5/22
Standard #:	22VAC40-73-930-A
Complaint related:	Yes
Description:	Based on observations of call device log and staff interview, the facility failed to act in a timely manner to the signaling device used by residents to alert direct care staff that they need assistance. EVIDENCE: 1. According to Staff #2 30 minutes is a good response time for any resident needing assistance by a direct care person. Anything over 30 minutes is viewed as excessive. 2. Resident #1?s pendant alarmed for 59:25 minutes on 10/17/2022; 42:36 on 10/19/2022; and 38:56 on 10/22/2022.
Plan of Correction:	Administrator and/or DON will audit call light log weekly to ensure timely answering of call lights X 3 months. Staff re-educated regarding timely response to all call lights. Administrator and/or DON will continue to conduct random call light audits to ensure continued compliance. Corrected date 11/15/22 [sic]