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: Sept. 8, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 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: 09/08/2022 9:45AM until 1:00PM. 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 07/29/2022 regarding allegations in the areas of: resident care and related services and resident accommodations and related provisions. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure the fall risk rating for a resident was updated at least annually. EVIDENCE: The most recent fall risk rating for resident 1 was dated 02/04/2021. Interview with staff 1 confirmed this was accurate.
Plan of Correction:	Annual Fall Risk Rating completed by Administrator on 9/8/22. Administrator to conduct audits of Annual Fall Risk Ratings, at random, monthly for 3 months and intermittently moving forward in order to ensure compliance with VDSS regulations.
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that private pay uniforms assessments (UAIs) were completed as required. EVIDENCE: The UAI for resident 1, dated 07/19/2022, indicated that the resident requires mechanical help only with eating/feeding. During on-site inspection it was expressed to the licensing inspector by staff 2 that resident 1 requires staff to sit her up in her bed prior to eating and sometimes spoon feed her food because she is not able to feed herself some days. Interview with staff 2 revealed that the resident does require mechanical help and human physical help with eating/feeding therefore the UAI is incorrect.
Plan of Correction:	Administrator completed updated UAI on 9/9/22 in order to accurately reflect the Resident?s needs in regard to eating/feeding. Admin./Designee to perform UAI audits, at random, monthly for 3 months and intermittently moving forward in order to ensure that Private Pay Uniform Assessments are completed and accurate as required by VDSS.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that all identified needs were addressed on individualized services plans (ISPs). EVIDENCE: The uniform assessment instrument (UAI) for resident 1, dated 07/19/2022, indicated that the resident requires physical human help and mechanical help with dressing. The ISP for the resident, dated 07/19/2022, indicated that the resident only requires physical human help with dressing. Interview with staff 2 revealed that the UAI is correct and the ISP is incorrect.
Plan of Correction:	Administrator completed updated ISP on 9/9/22 in order to accurately reflect the Resident?s needs in regard to dressing. Administrator/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward in order to ensure that all identified resident needs are addressed accurately on Individualized Service Plans.
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure when hospice care is provided to a resident, the services provided by the licensed hospice organization are included on the individualized service plan (ISP). EVIDENCE: Resident 1 receives hospice care; however, the ISP for the resident, dated 07/19/2022, does not indicate which hospice organization is providing hospice services to the resident nor what services the hospice organization is providing to the resident.
Plan of Correction:	Administrator completed updated ISP on 9/9/22 in order to accurately reflect the resident?s needs in regard to services provided by a Licensed Hospice Organization. Administrator/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward in order to ensure that the entity name and services provided are included in the plan of care per VDSS standards.
Standard #:	22VAC40-73-460-H
Complaint related:	No
Description:	Based on observation, resident record review, and staff interview, the facility failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident are met. EVIDENCE: During on-site inspection on 09/08/2022, the licensing inspector observed at approximately 10:03AM a Styrofoam container on the resident?s bed side tray that contained mechanically altered food and a Styrofoam cup of coffee. The licensing inspector observed resident 1 lying in her bed at this time as well. This was also observed by staff 2 and staff 2 revealed that the Styrofoam container contained the resident?s breakfast and that kitchen staff bring the containers to residents? room and then direct care staff are to feed the residents that require feeding assistance. Staff 2 acknowledged that the food had not been given to the resident. The licensing inspector and staff 2 also noted that the resident was holding an empty Styrofoam cup in her right hand. Interview with staff 4 and 5 revealed that they were the staff responsible for the resident on this date. Staff 4 stated the following: ?I didn?t come into her room this morning because I forgot to come and feed her? and when asked what she would do for the resident staff 4 stated that ?I would come in and sit her up in her bed and feed her.? The resident expressed that she wanted water and staff 2 proceeded to get a small bottle of water with a straw and the licensing inspector observed that the resident drank half of the small bottle of water and staff 2 held the bottle of water for the resident so she could drink.
Plan of Correction:	Reeducation was provided to the two staff members directly involved in the occurrence on 9/8/22. Reeducation included: Nutrition and Hydration as well as meeting and documenting identified needs of the resident. Education to be provided to all Team Members of the facility by 9/21/22 in regard to current residents requiring assistance with eating/feeding as well as the importance of proper nutrition and hydration and scheduled meal times.
Standard #:	22VAC40-73-660-B
Complaint related:	No
Description:	Based on observation made of the facility?s physical plant and resident record review, the facility failed to ensure that dietary supplements kept in resident rooms are only permitted for residents who are indicated as capable of self-administering their own medications. EVIDENCE: The refrigerator resident 1?s room contained multiple containers of Ensure original supplement. The uniform assessment instrument (UAI) for resident 1, dated 07/19/2022, indicated that the resident requires all medications to be administered by professional nursing staff and/or registered medication aides (RMAs). The record for resident 1 contained a physician?s order, dated 08/23/2022, for Ensure drink one bottle/carton by mouth twice daily for lack of appetite/weight loss if patient can tolerate and does not contain information that the resident can keep the aforementioned supplement in their room.
Plan of Correction:	Order obtained from Hospice FNP on 9/15/22 for 1 Ensure prn to be kept at bedside for supplement. Family member notified of necessity of a physician or other prescriber?s order in order to maintain medications or supplements in the resident?s room. DON/Designee to review Nutritional Supplement orders moving forward in order to ensure that appropriate orders are obtained when such supplements are requested and deemed appropriate to be kept in the Resident?s room.
Standard #:	22VAC40-73-870-A
Complaint related:	No
Description:	Based on observations made of the facility?s physical plant, the facility failed to maintain and keep clean the interior of the building. EVIDENCE: The carpet next to resident 1?s bed and in front of the door of the closet contained multiple stains. Underneath the resident?s bed the licensing inspector observed a balled up tissue, a white, small piece of cardboard, and other multiple small items of objects and the wall behind the head of the resident?s bed contained multiple, black scuff marks.
Plan of Correction:	Carpets in the involved room have been cleaned and sanitized as well as paint touch ups several times prior to inspection. Carpets scheduled to be replaced by 9/16/22. Scuffed marks and debris removed on 9/8/22. Maintenance Director or Designee to monitor cleanliness and maintenance of resident room once weekly moving forward.