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:

Complaint Related: No

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]