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: May 15, 2023

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 05/15/2023, 10:15am to 5:20pm 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: 95 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Noon medication pass, lunch, activities Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure the fall risk rating was updated at least annually for one of nine resident files reviewed. EVIDENCE: 1. Resident #8 was rated at the assisted living level of care on the Uniform Assessment Instrument (UAI) dated 09/23/2022. 2. Resident #8 was admitted to the facility on 04/19/2022; there was no documentation acknowledging a fall risk rating had been completed during the previous 12 months. 3. Staff #5 completed a fall risk rating for resident #8 during the onsite inspection on 05/15/2023.
Plan of Correction:	Corrected during inspection. Administrator and/or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days, for one of nine resident files reviewed. EVIDENCE: 1. Resident #8 was admitted to the facility on 04/19/2022; there was no documentation found in the record indicating the facility ascertained whether the resident is a registered sex offender. 2. The sex offender screening for resident #8 was obtained by staff #5 during the onsite inspection on 05/15/2023.
Plan of Correction:	Corrected during inspection. Administrator and/or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
Standard #:	22VAC40-73-410-A
Description:	Based on a review of resident records, the facility failed to document acknowledgement of having received orientation for one of nine resident files reviewed. EVIDENCE: 1. Resident #1 was admitted on 02/28/2022. The New Resident Orientation form in the record for resident #1 was signed and dated by the administrator at that time on 03/01/2022, however it was otherwise completely blank and not signed and dated by the resident and/or the legal representative.
Plan of Correction:	Resident?s orientation check list completed with resident by Administrator on 6/2/23. Administrator and/or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on Individualized Service Plans (ISPs) for two of nine resident files reviewed. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) dated 05/03/2023 in the record for resident #6 identifies eating/feeding as an area in which the resident needs help (human help only, supervision). The Individualized Service Plan (ISP) dated 05/09/2023 in the record for resident #6 states ?Resident is able to feed herself at this time. Encourage independence.? The ISP does not indicate supervision is being provided, but staff #5 confirms resident does receive supervision/cueing as needed while eating. 2. The UAI dated 09/23/2022 for resident #8 identifies bathing as an area in which the resident needs help (mechanical help only, shower chair and grab bars). The ISP dated 09/23/2022 for resident #8 indicates the resident is to utilize grab bars as needed, but does not indicate the resident may use a shower chair. 3. The UAI dated 09/23/2022 for resident #8 identifies money management as an area in which the resident needs help; the ISP dated 09/23/2022 for resident #8 does not address this need.
Plan of Correction:	ISPs for two residents updated by Administrator on 5/29/23. All ISPs to be randomly audited ongoing to ensure continued compliance. [SIC]
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records, the facility failed to maintain written acknowledgement of annual review of rights and responsibilities of residents in assisted living facilities for one resident. EVIDENCE: 1. Resident #7 was admitted to the facility on 05/01/2015; there was no documentation acknowledging annual review of resident rights and responsibilities observed in the record for resident #7. 2. The most recent acknowledgement of annual review of resident rights and responsibilities occurred in 2021.
Plan of Correction:	Resident rights completed with resident/Daughter by Administrator on 6/1/23. Administrator or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the noon medication pass and the medication cart audit, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. 1. On medication cart #1, there was no open date on resident #10?s Refresh Tears 0.5mL, one drop in each eye three times daily.
Plan of Correction:	Eye drops have an open date of 5/15/23 completed by Med Tech on cart 5/15/23. All med carts to be audited for compliance by DON or designee by 6/10/23 and randomly ongoing to ensure continued compliance. [SIC]