VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Crozet Campus
1220 Crozet Avenue
Crozet, VA 22932
(540) 810-6200

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Oct. 28, 2020 and Oct. 30, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Technical Assistance:

Standard 22 VAC40-73-450F:Discussed ensuring that all resident needs based on assessments including the Uniform Assessment Instrument, Fall Risk Ratings, etc. are included on the Individualized Service Plans (ISP). Standard 22 VAC40-73-620B ? Ensure that the dietician documents all residents seen while at the facility and not just residents with changes needed.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on October 28, 2020 and concluded on October 30, 2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 87. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records, five staff records, medication administration records, fire and health inspections, health care oversight, pharmacy and dietician reviews, individualized service plans, and staff schedules submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance 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). Please contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on a review of the Fall Risk Rating and Individualized Service Plan (ISP) documents, the facility failed to ensure that the ISP was updated as needed as the condition of the resident changes. Evidence: The Fall Risk Rating dated 08/31/2020 for resident #4 contains handwritten documentation of the following under the column Goal/Preventative Measure: 1. Q1 hour safety checks 2. Encourage resident to use pendant or Pull cord of assistance needed. 3. Assure resident has non slip socks on or shoes Resident #4?s ISP signed by resident #4 and the administrator and dated 6/8/2020 was not updated to reflect the Goal/Preventative measures handwritten on the Fall Risk Rating.
Plan of Correction:	ISP was corrected following inspection on 10/30/2020. Admin/DON will review ISP's at random, quarterly to ensure correctiveness.