VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Abingdon Campus
15089 Harmony Hills Lane
Abingdon, VA 24211
(276) 619-4572

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Dec. 18, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 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: 12/18/2023, 2:35pm to 3:57pm 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 12/18/2023 regarding allegations in the area(s) of: Resident accommodations and related provisions. Number of residents present at the facility at the beginning of the inspection: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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(allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-750-B
Complaint related:	Yes
Description:	Based on observations made during a tour of the building, the facility failed to ensure bedrooms shall contain a separate bed with comfortable mattress, springs, and pillow for each resident. EVIDENCE: 1. During a visit to the facility on 12/18/2023, the licensing inspector observed no bed in the room for resident #1. There was a twin-size mattress on the floor of the room for resident #1. 2. Per staff #1, she was notified by staff #2 during day shift on 12/17/2023 that the bed for resident #1 was broken and had been removed from the room. 3. Per staff #2, she observed the bed to be broken at approximately 2:30pm on 12/17/2023. She removed the bed frame from the room and notified staff #1.
Plan of Correction:	Maintenance, nursing and management staff educated by 12/20/2023 on ensuring residents have the required furniture and it is in good condition. Staff to be educated on appropriate steps to take. Administrator/Designee will check resident #1?s bed once weekly for 3 weeks and then once monthly for 3 months to ensure compliance. Son brought in new bed frame on 12/18/2023. [SIC]
Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on observations made during a tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. EVIDENCE: 1. Per staff #1, she was notified by staff #2 during day shift on 12/17/2023 that the bed for resident #1 was broken and was removed from the room. 2. Per staff #2, she observed the bed to be broken at approximately 2:30pm on 12/17/2023. She reports the bed frame was bent in the middle. 3. Approximately half of the surface of the mattress for resident #1 was observed to be covered in light brown stains.
Plan of Correction:	Maintenance, nursing and management staff educated by 12/20/2023 on ensuring residents have the required furniture and it is in good condition. Staff to be educated on appropriate steps to take. Care plan updated for resident removing bedding. Administrator/Designee will check resident #1?s bed once weekly for 3 weeks and then once monthly for 3 months to ensure compliance. Son brought in new bed frame on 12/18/2023. [SIC]