VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Prince William Campus
10140 Hastings Drive
Manassas, VA 20110

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Aug. 17, 2023 and Aug. 18, 2023

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Mixed Population

Comments:

Date of Inspection: August 17 and 18, Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 17 Number of records reviewed and interviews conducted- 8 records (staff and residents), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meals and activities. The Licensing Inspector reviewed the following at the time of inspection: Healthcare Over Sight, fire drills, first aid kits, menus, activity calendars, health department and fire marshal reports. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-1070-B
Description:	Based on direct observation by the Licensing Inspector, it was determined that the facility staff failed to have materials that may be harmful to the residents inaccessible. Evidence: The cleaning care was at the end of the 100 hall outside a resident's room. The cleaning supplies were not in sight or supervision of any staff.
Plan of Correction:	Administrator/Designee provided re-education to the Team Member(s) on housekeeping duty on 8/17/23 and 8/24/23 regarding the proper storage of materials that may be harmful to residents. Administrator/Designee to perform weekly audits for q3 months and at random moving forward in order to ensure adherence to VDSS Standards.
Standard #:	22VAC40-73-440-H
Description:	Based on resident record review and staff interview, it was determined that the facility staff failed to have current reassessments of the Uniform Assessment Instruments (UAI) within the resident files. Evidence: There was no documentation of current UAIs in resident records: Resident As UAI was dated June 23, 2022, Resident Ds UAI was dated March 8, 2022, Resident Es UAI was dated March 9, 2022 and Resident Fs UAI was dated April 18, 2022.
Plan of Correction:	Administrator/ Designee to conduct full Resident Record audits by 9/15/2023 in order to ensure that the Resident Records include current reassessments of Uniform Assessment Instruments. Administrator/Designee to perform random Resident Record audits monthly regarding UAIs for q3 month and at random moving forward to ensure adherence to VDSS Standards.
Standard #:	22VAC40-73-560-E
Description:	Based on resident record review and staff interview, it was determined that resident records were not kept current as required. Evidence: Resident A, B, C, D, E, and F had no current documentation in the record.
Plan of Correction:	Administrator/Designee to conduct full Resident Record audits by 9/15/2023 in order to ensure that the Resident Records include current documentation. Administrator/Designee to perform random Resident Records audits monthly, for q3 months and at random moving forward to ensure adherence to VDSS Standards.
Standard #:	22VAC40-73-660-A-1
Description:	Based on direct observation by the Licensing Inspector, the medication cart that was in the front hall directly across from the front door was left open and unsecured. Evidence: The medication cart was left unsecured and unattended in the main lobby of the facility.
Plan of Correction:	Administrator/Designee provided re-education to the RMA on duty on 8/17/2023. Administrator/Designee to provide re-education to all Licensed Medication Staff by 8/25/2023 regarding proper storage of mediations. Administrator/Designee to perform proper Medication Cart Storage audits weekly for q3 and at random moving forward in order to ensure adherence to VDSS Standards.
Standard #:	22VAC40-73-940-A
Description:	Based on facility record review and staff interview, it was determined that the facility failed to comply with the Virginia Statewide Fire Prevention Code with an annual inspection. Evidence: The facility had documentation of an annual inspection for April 6, 2022. This was not current as required.
Plan of Correction:	Administrator/Designee provided re-education to pertinent Team Members on 8/18/2023 regarding compliance with the Virginia Statewide Fire Prevention Code requiring at least an annual inspection by the appropriate fire official and retention of said reports. Fire Department inspection was completed on 8/23/2023. Administrator/Designee to monitor annually and as needed for Fire Safety VDSS Standard adherence.
Standard #:	22VAC40-73-980-B
Description:	Based on direct observation by the Licensing Inspector and the Administrator, it was determined that the facility failed to have a complete first aid kit in the facility motor vehicle. Evidence: The facility motor vehicle did not have a complete first aid kit as required.
Plan of Correction:	Administrator/Designee obtained a complete first aid kit on 8/23/2023 and placed it inside the facility motor vehicle. Administrator/Designee to perform monthly audits moving forward to ensure that the first aid kit is present, located in a designated place, containing the required items as noted by VDSS Standards.
Standard #:	22VAC40-73-990-C
Description:	Based on facility record review, it was determined that the facility failed to have documentation of exercises in which the procedures for resident emergencies are practiced. Evidence: the facility records had no documentation of resident emergency drills every six months as required.
Plan of Correction:	Administrator/Designee to ensure that all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced by 8/24/2023. Administrator/Designee to ensure the moving forward this training is performed at least once every six months as required by VDSS Standards.