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: Aug. 4, 2023

Complaint Related: Yes

Areas Reviewed:

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

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: 08/04/2023, 10:55am to 3:07pm 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 07/25/2023 regarding allegations in the area(s) of: Personnel, resident care and related services, building and grounds. Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 8 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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; area(s) of non-compliance with standard(s) or law were: Resident care and related services, building and grounds. A violation notice was 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 #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on a tour of the building and interviews with staff, the facility failed to assume general responsibility for the health, safety and well-being of the residents. EVIDENCE: 1. Resident #1 has two cats in her room. 2. Per interview with staff #1, he confirmed there has been an ongoing issue with the cats and related foul smell in her room. 3. During the tour of the building on 08/03/2023, LI observed the two cats in the room for resident #1, and an odor resembling urine. 4. Per video footage provided to LI, ants were observed to be crawling on the face, neck/chest and arms of resident #2 while she appeared to be resting. The video was dated March 18, 2023, 6:21am. 5. Per interview with staff #1, he was promptly notified of the incident regarding the ants observed on resident #2 and reports the situation was addressed immediately.
Plan of Correction:	Housekeeping staff and nursing staff will check Resident #1 's room three times a week and clean as appropriate to reduce odors in the room. Housekeeping will complete a sign off sheet that this has been completed. Resident #1 has been on 30 day notice of discharge and will be transferring to another facility as soon as possible. All insects reported to staff or observed by staff will be addressed immediately by Maintenance staff and exterminator will be contacted to treat needed areas. [SIC]
Standard #:	22VAC40-73-840-B
Complaint related:	No
Description:	Based on observations made during a tour of the building and review of facility policies and documentation, the facility failed to adhere to their policy regarding pets living on the premises. EVIDENCE: 1. Per the facility?s Pet Policy included in the Residency Agreement, it states ?One (1) pet per unit (dog or cat).? 2. Based on facility documentation and observations made by LI during a tour of the building, there were two cats in the room for resident #1. 3. Per veterinary records maintained at the facility, the cats housed in the room for resident #1 last had an exam and vaccinations on 02/11/2021. The records indicate the cats should have had another exam with vaccinations by 02/11/2022.
Plan of Correction:	Guardian of resident #1 has been contacted and informed that one of this resident's cats will need to be removed from facility and that remaining cat will need to be vaccinated as soon as possible and records provided to this facility. Administrator or designee will check vet records on admission and annually to ensure compliance. [SIC]
Standard #:	22VAC40-73-870-B
Complaint related:	Yes
Description:	Based on observations made during a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale and musty odors. EVIDENCE: 1. The room for resident #1 was observed to have a foul odor resembling urine at 11:35am on the date of inspection. 2. During the inspection staff # 1 reported that the odor in resident # 1?s room was bad and offered a mask for LI wear due to the strong urine odor. 3. A strong odor resembling urine was observed in room #130 at 11:55am on the date of inspection, as well as a soiled brief in the trash can.
Plan of Correction:	All direct care staff will be re-educated to ensure that residents are rounded on every 2 hours on AL side of facility and soiled items removed immediately. Will reeducate all direct care staff to address all odors observed immediately. [SIC]
Standard #:	22VAC40-73-870-D
Complaint related:	Yes
Description:	Based on a video recording and interviews with staff, the facility failed to ensure the building shall be kept free of infestations of insects and vermin. EVIDENCE: 1. A video recording showed ants crawling on resident #2 on 03/18/2023. 2. Staff #1 confirmed the presence of ants in the room for resident #2 in March 2023 and reports a spray was used when the ants were first observed and the exterminator came to the facility the following week.
Plan of Correction:	All insects observed by staff or reported to staff will be reported immediately to Maintenance staff to be addressed. Exterminator will be contacted to arrange for them to treat appropriate areas. [SIC]
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to ensure for each resident with an inability to use the signaling device, to document the rounds that were made, including the time of the rounds. EVIDENCE: 1. Resident #3 was admitted to the secure unit on 11/01/2022 with a diagnosis of dementia and was noted to be unable to recognize danger. 2. Per a progress note dated 01/17/2023, ?Resident (#3) was found on back in floor in room at approx. 0800. States that she had fallen and unable to let staff know.? 3. The individualized service plan (ISP) dated 11/01/2022 states ?Rounds to be performed Q1 hours and call lights to be in place and operational.? 4. The caregiver assignment sheet shows documentation is only made one time per 8 hour shift, not each hour.
Plan of Correction:	New one hour rounding sheet has been created and will be signed off by direct care staff for hourly rounds. These will be maintained with ADL records for each individual resident. DON or designee will conduct random audits to ensure compliance. [SIC]