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: April 11, 2024 , May 16, 2024 and May 24, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 04/11/2024 10:58am to 12:45pm, 05/16/2024 12:04pm to 12:21pm, 05/24/2024 12:36pm to 12:41pm 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 03/18/2024 regarding allegations in the area(s) of: Resident care and related services, health care services. Number of residents present at the facility at the beginning of the inspection: 72 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: n/a Number of interviews conducted with staff: 6 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 #:	22VAC40-73-470-C
Complaint related:	Yes
Description:	Based on review of facility documentation and interviews with staff, the facility failed to ensure health care services shall be provided to prevent clinically avoidable complications, including pressure ulcer development or worsening of an ulcer. EVIDENCE: 1. Resident #1 was admitted to hospice on 12/06/2023. 2. Per notes by staff #1, a skin tear was observed on resident #1?s right hip on 01/01/2024. Staff #1 confirmed during a phone interview on 05/06/2024 she did observe the skin tear and reports she covered it with a ?circle band-aid.? She reported the Director of Nursing (DON) and hospice should be notified when a skin impairment is observed, because unlicensed staff are not permitted to provide first aid for any skin impairment requiring ?anything bigger than a band-aid.? Staff #1 reported she sent a text to staff #2 notifying her of the skin impairment, but reported she did not notify hospice. 3. Staff #3 worked with resident #1 on 01/02/2024 and documented in notes the presence of the skin tear. She reported during a phone interview on 05/06/2024 she was aware of the skin tear but did not see it because it was covered. She reported she did not clean or dress the skin impairment because unlicensed staff ?are not allowed.? She reported if a skin impairment is observed and the resident is receiving hospice services, hospice is to be notified. Otherwise, she stated skin impairments are to be reported to the DON. 4. The skin tear was documented again in notes on 01/04/2024, on the Daily Charting forms from 01/01/2024-01/05/2024 and the 24 Hour Communication Report on 01/01/2024, 01/03/2024 and 01/04/2024. 5. Per notes by staff #4 on 01/05/2024, resident #1 had a wound on her right hip. Per phone interview with staff #4 on 05/06/2024, she did not provide any care related to the wound as she is unlicensed, and she noted wounds are to be reported to hospice or the DON. 6. Per staff #2, she was not notified on 01/01/2024 when the skin tear was initially observed. She reports she was notified by staff #5 on 01/05/2024. She reported the wound was covered with a gauze pad and taped on all four corners when she was notified, and she was not aware of who dressed the wound. She stated the wound was ?at least a stage 2? at that point. Staff #2 reported individuals that should be notified when a skin impairment is observed include the assistant DON (ADON), DON or other facility management staff, family and hospice staff. She reported unlicensed staff are only permitted to perform ?simple first aid.? 7. Per hospice notes, a hospice nurse visited resident #1 on 01/03/2024, but there was no documentation regarding a skin tear or a wound. A different hospice nurse visited on 01/05/2024 from 3:00pm to 3:45pm, with no documentation regarding a skin tear or a wound. The same nurse visited again on 01/05/2024 from 4:55pm to 5:40pm and provided care for an ?unstageable pressure ulcer/injury.? Her notes documented ?Pressure areas to right hip and right ear, not reported earlier in visit.? Wound care was provided by hospice staff again on 01/07/2024 and 01/09/2024. 8. There was no documentation provided by the facility that indicated direct care staff notified the ADON, DON, other facility management staff or hospice staff when the skin tear was initially observed on 01/01/2024, or at any time prior to 01/05/2024.
Plan of Correction:	DON/Administrator to provide re-education to all RMAs and LPNs to ensure that with all skin issues that DON/Lavender Hills Coordinator are notified and for all residents on Hospice/Home Health Services, that these agencies are notified as well. DON/Administrator to to provide reducation to all RMAs and LPNs to ensure all skin issues and notifications to management and outside agencies are documented appropriately in residents? charts. DON/Administrator to perform audits at random for 3 months and intermittently moving forward in order to ensure compliance. [SIC]