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 and July 5, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

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: 05/15/2023, 2:05pm to 2:40pm, 07/05/2023, 1:20pm to 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/08/2023 regarding allegations in the area(s) of: Resident care and related services, administration of medications 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: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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 the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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. 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 #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to ensure the comprehensive Individualized Service Plan includes an accurate description of who will provide certain services, and failed to address all identified needs on Individualized Service Plans (ISPs). EVIDENCE: 1. The ISP updated 02/07/2023 for resident #1 indicates all direct care staff, hospice staff and family will provide assistance with bathing. Collateral #1 reports family never assisted resident #1 with bathing and would not have agreed to being added to the ISP in this area. 2. The Uniform Assessment Instrument dated 08/05/2022 for resident #1 identifies mobility, mechanical and human help, physical assistance, as an area in which the resident requires assistance. The ISP dated 08/17/2022 for resident #1 states with regard to mobility: ?Resident is to utilize walker/ w/c when ambulating, as needed, for steadiness when being mobile throughout the community.? In the column labeled Persons Who will Provide Services, the ISP states: ?self?.
Plan of Correction:	This resident has been discharged. Moving forward ISPs will be audited sporadically to assist to prevent errors. [SIC]
Standard #:	22VAC40-73-450-E
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to ensure the Individualized Service Plan (ISP) shall be signed and dated by the resident or his or her legal representative. EVIDENCE: 1. The ISP dated 03/22/2023 provided to LI is not signed by resident #1 or resident #1?s legal representative. 2. The ISP updated on 02/27/2023 and 03/07/2023 provided to LI was originally signed by the legal representative for resident #1 on 12/05/2022 but is not signed by resident #1 or the legal representative for resident #1 acknowledging updates on 02/27/2023 and 03/07/2023. 3. Collateral #1 reports the family did not receive an updated ISP after the 03/07/2023 assessment.
Plan of Correction:	This resident has been discharged. Moving forward will work to ensure all residents and/or responsible parties sign ISPs and are provided with a copy upon their signature. [SIC]
Standard #:	22VAC40-73-460-F
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to notify next of kin of any incident of a resident falling or wandering from the premises, whether or not it results in injury. The facility failed to include documentation of notification, including time, caller and person notified. EVIDENCE: 1. Per collateral #1, next of kin was not notified when resident #1 fell on 01/22/2023. 2. There was an incident report that included a date of when next of kin was notified, but it did not include a name of who was notified, time of notification or identity of staff person making the notification. 3. There was no documentation of the fall or notification of next of kin in interdisciplinary notes (other falls and notifications were documented in interdisciplinary notes).
Plan of Correction:	Will re-educate all medication staff regarding notifying resident and/or responsible parties of incidents and ensuring this is documented. DON or designee will complete random audits of incident reports to assist with ensuring compliance. [SIC]
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on information received via anonymous complaint and per interview with staff, 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. EVIDENCE: 1. Per report from collateral #1, on 03/04/2023, staff #3 documented on the MAR she administered the 6am dose of Carbidopa-Levodopa ER 50-200 MB TBCR, give twice daily for Parkinson?s disease, when she did not actually administer the medication. Per documentation received from staff #1, staff #3 ?stated meds were mistakenly signed off as given and were in fact not given.?
Plan of Correction:	This resident has been discharged. Employee involved has been addressed and re-educated as well as all medication staff being re-educated. DON or designee will complete random audits of Medication carts and Medication Administration Records to ensure compliance. [SIC]
Standard #:	22VAC40-73-930-A
Complaint related:	Yes
Description:	Based on a review of two 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. EVIDENCE: 1. The call system log was reviewed for two pendants from the date ranges of 09/01/2022-02/10/2023 for pendant 240 and 12/01/2022-03/30/2023 for pendant MC 102. According to an interview with staff #1 and staff #2, they both agreed a 30-minute response time is an appropriate time frame. 2. Pendant 240 requested assistance on 12 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 240: 09/21/2022 ? 1:09pm 00:36:11 09/30/2022 ? 6:59am 00:44:11 10/07/2022 ? 6:51am 00:32:19 10/11/2022 ? 7:04am 00:30:55 10/16/2022 ? 7:00am 00:34:58 10/27/2022 ? 6:59am 00:33:23 11/06/2022 ? 6:50am 01:23:37 11/09/2022 ? 6:54am 00:38:42 11/11/2022 ? 7:16am 00:40:02 11/12/2022 ? 7:04am 00:54:32 (Bath) 11/13/2022 ? 6:57am 00:32:41 11/20/2022 ? 11:33am 00:31:27 (Shower) 11/30/2022 ? 7:51pm 00:34:32 3. Pendant MC 102 requested assistance on six 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 MC 102: 12/08/2022 ? 3:39pm 00:31:20 12/13/2022 ? 2:33pm 00:41:59 12/27/2022 ? 9:06am 00:47:13 03/15/2023 ? 6:43pm 00:31:52 03/15/2023 ? 7:20pm 00:41:28 03/29/2023 ? 7:38pm 00:48:23
Plan of Correction:	All staff have been re-educated regarding timely answering of call lights. The administrator or designee will monitor call lights periodically to ensure compliance. [SIC]