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: May 9, 2024 and May 10, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/09/2024 10:10am to 2:31pm and 05/10/2024 9:45am to 3:27pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-210-B
Description:	Based on a review of staff records and interviews with staff, the facility failed to ensure that in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. EVIDENCE: 1. The date of hire for staff #2 was 04/26/2022. 2. Between 04/26/2023 and 04/25/2024, staff #2 attended five total hours of training. 3. Between 01/01/2023 and 12/31/2023, staff #2 attended 13.25 hours of training. 4. Per staff #4 and #5, the documentation provided includes all training hours attended by staff #2.
Plan of Correction:	All staff of facility will have training hours tracked from date of hire to anniversary date. DON will monitor nursing staff monthly to ensure that hours are completed in a timely manner. BOM will monitor all other department?s staff monthly to ensure all training hours are completed timely. [SIC]
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to obtain all required personal and social information on a person prior to or at the time of admission to an assisted living facility, for four of the seven resident records reviewed. EVIDENCE: 1. Resident #2 was admitted to the facility on 02/25/2023; the section entitled "Current behavioral and social functioning including strengths and problems? on page 2 of the Resident - Personal/Social Data form was not completed. 2. Resident #3 was admitted to the facility on 04/20/2022. The Resident - Personal/Social Data form did not contain the following information: Previous mental health or intellectual disability services history, if any, and if applicable for care or services; current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care or services. (There was no second page, only the first was completed and in the record) 3. Resident #4 was admitted to the facility on 04/17/2023; the section entitled "Current behavioral and social functioning including strengths and problems? on page 2 of the Resident - Personal/Social Data form was not completed. 4. Resident #5 was admitted to the facility on 04/12/2024; the section entitled "Current behavioral and social functioning including strengths and problems? on page 2 of the Resident - Personal/Social Data form was not completed.
Plan of Correction:	Administrator will ensure all current social data sheets are corrected and will review periodically moving forward to ensure all information is correctly documented on the social data sheets. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on the comprehensive individualized service plan (ISP) for two of the seven resident files that were reviewed. EVIDENCE: 1. The ISP for resident #2 dated 02/05/2024 identifies ?FULL CODE? as a need, however, a Do Not Resuscitate (DNR) order dated 04/08/2024 was observed in the record for resident #2. The ISP was not updated to reflect the change in status. 2. Resident #2 was admitted to the safe secure unit on 02/25/2023; this need was not addressed on the ISP dated 02/05/2024 for resident #2. 3. Resident #6 was admitted to the safe secure unit on 01/22/2020; this need was not addressed on the ISP dated 12/13/2023 for resident #6.
Plan of Correction:	Administrator has conducted an audit of all resident code status to ensure they are correct. Administrator and/or DON will conduct periodic code status audits moving forward to ensure accuracy. [SIC]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. EVIDENCE: 1. There was no menu posted in the safe secure unit at the time of inspection on 05/09/2024, 11:05am. 2. The licensing inspector checked again for the menu at 11:28am the same date and it had not yet been posted.
Plan of Correction:	Menu was posted on Secure Care Unit that afternoon. The administrator and/or Dining Manager will do random checks to ensure menus are up and the correct date. [SIC]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, the facility failed to implement a written plan for medication management, including methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. The May 2024 Medication Administration Record (MAR) and physician?s order dated 02/02/2024 indicate resident #11 receives Lantus 100U/ML Solostar Injection, Inject 8 units sub-q every morning for diabetes mellitus type II. The Lanutus SoloStar pen observed in the medication cart for resident #11 had an open date of 03/13/2024. Instructions on the manufacturer label affixed to the medication state: ?Use within 28 days after initial use.? The medication cart audit occurred on 05/10/2024. 2. The May 2024 MAR and physician?s order dated 02/17/2024 indicate resident #12 receives Insulin Aspart Soln Pen-Injector 100 unit/ML (Generic for NovoLog FlexPen), Check FSBS twice a day ? before breakfast and at bedtime and inject per sliding scale: 0-180=0U; 180-250=6U; 251-299=8U; 300 and greater=10U for diabetes mellitus type II. There were two NovoLog FlexPens observed in the medication cart for resident #12; one appeared nearly empty and the other nearly full and neither contained an open date. Per manufacturer instructions found at www.mynovoinsulin.com, unused NovoLog pens can be stored at room temperature up to 86 degrees Fahrenheit for up to 28 days; after use, NovoLog pens can be kept at room temperature (below 86 degrees Fahrenheit) or refrigerated for up to 28 days. The instructions also state the medication should be disposed of after 28 days, even if there is insulin left in the pen.
Plan of Correction:	Both insulin pens were removed from cart immediately and replaced with new insulin pens that were labeled per policy. DON and/or designee will conduct med cart audits monthly moving forward to ensure no outdated medications are left on the carts. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In the bathroom for resident room #H115, there were several used towels and washcloths observed in the shower. In the same bathroom, dark spots were observed on the floor to the right of the base of the toilet. 2. In the bathroom for resident room #H111, there were several dark spots observed on the floor in front of the shower. 3. In resident room #112, there were several dark spots observed on the lower left side of the back of the entry door to the room, resembling a liquid that may have been spilled/splashed onto the door.
Plan of Correction:	Room 112 door was cleaned and all spots removed on 5/21/24. Rooms H111 and H115 will have vinyl flooring replaced to eliminate the spots. Staff re-educated on 5/21/24 to ensure no towels or washcloths are left in the showers. Administrator and/or maintenance director will randomly check flooring for any stains or issues moving forward. DON will periodically monitor showers to ensure no towels or washcloths have been left in these areas. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during a tour of the building, the facility failed to ensure that 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. In the bathroom for resident room #219, the front portion of the toilet seat and rim of the toilet appeared slightly soiled with yellow/dark spots. 2. In the bathroom for the resident room #201, the bottom portion of the shower curtain appeared soiled/stained. 3. In resident room H119, the chest of drawers to the left of the window had a missing knob on the top drawer (knob was found on floor and placed on top of the chest of drawers), and the handle on the bottom drawer was partially detached. In the same room, the cover of the seat cushion on the chair by the bed had been removed (it was laying on the back of the chair), and the seat cushion had several visible stains on approximately one third of the surface.
Plan of Correction:	Toilet in room 219 cleaned to ensure all soiled spots were removed, 201 the shower curtain was removed washed and returned, and H119 repairs made to dresser as well as chair that was soiled has been removed and replaced with a new chair. The Maintenance Director will make random room checks to ensure cleanliness moving forward. [SIC]