VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Williamsburg Campus
1807 Jamestown Road
Williamsburg, VA 23185
(757) 941-5099

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Sept. 29, 2021

Complaint Related: No

Areas Reviewed:

Part VI: Resident Care and Related Services Part VII- Buildings and Grounds Part Ix: Emergency Preparedness Part II: Administration and Administrative Services

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. An announced initial inspection was conducted on-site on September 29, 2021. The licensee's representative was contacted by email to initiate the inspection. The inspector conducted a joint on-site inspection with another inspector from the Peninsula Licensing Office. A tour of the facility's Buildings and Grounds were conducted, all required posted documents, menus, activity calendar, evacuation posting, food manual, first aid kit and signaling device were observed. 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

Violations:

Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. During a tour of the facility with staff #1 and #2, the following was observed in building C: a.The floor in the bathroom floor and carpet in room C-1 had areas of debris and sand. The wall in the bathroom, top left area near the entrance had a 3 X 4 inch hole in the wall. A bottom portion of a mattress and chair was located in the middle of floor in room C-1. A metal ladder and metal rod approximately seven feet long was propped against the wall near the TV in the common area. A coffee machine and table tray were located on the floor to the right wall in the common area. b.Cobbed webs were observed in the left lower windows located near the exit door to the white caged patio. 2.The exhaust fan in the bathroom in A-16 was covered in brown and light grey dust. A medication cart was also stored in the bedroom area of the room. 3. Staff #1 and #2 acknowledged Building C was not kept clean and in good repair and was not available for the receiving of residents.
Plan of Correction:	1.(a) The bathroom floor and carpet in room C-1 was cleaned of all debris and sand on 9/30/21. Maintenance Director to perform, with Administrator oversight, monthly walk through of the building in order to ensure the building is in appropriate repair. The hole in the wall was prepared on 9/30/21 by the Maintenance Director. Maintenance Director, with Administrator oversight, to perform monthly walk through of the building in order to ensure the building Is in appropriate repair. The mattress and chair were set up appropriately in room C-1 on 9/30/21 by Maintenance Director. Maintenance Director, with Administrator oversight, to perform monthly walk through of the building in order to ensure that the building is ln appropriate repair. Metal ladder and rod and coffee machine and table tray were removed from common area on 9/30/21 by Maintenance Director. Maintenance Director, with Administrator oversight, to perform weekly walk through of building in order to ensure building is in good repair. b. Cobbed webs to be removed from lower windows by 10/8/21 by Maintenance Director. Maintenance Director, with Administrator oversight, to perform monthly walk through of the building in order to ensure the building is in good repair. 2. Exhaust fan in the bathroom in A-16 to be cleaned by Maintenance Director by 10/4/21. Maintenance Director, with Administrator oversight, to perform monthly walk through of the building in order to ensure the building is in good repair.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interview, the facility failed to ensure all furnishings, fixtures, equipment, including furniture, window coverings, sinks, toilets, tubs, and showers, shall be kept clean and in good repair and condition. Evidence: 1. During a tour of the facility with staff #1 and #2, the air conditioning units in the bedrooms in Building C were not operable. a.The covering to the units in rooms C-1 and C-12 were separated from the unit. According to staff #2, the contractor were working in the building, conducting a ?mold mediation?. The vents in the ceiling in building C were observed covered with paper and taped closed with green colored tape. b.The toilet bowl was heavily stained a black- brown color, it remained that color after being flushed. 2. During a tour of the facility with staff #1 and #2, the following were observed in Building B: a.Bedroom #B-8 contained the facility?s 96 hour food and water supplies. b.Bedroom #B-15 contained decoration items and boxes 3. The signaling cord was pulled in rooms C-1 and B-8. Because the system was not connected to the facility?s pager system, therefore staff did not respond. 4. Staff #1 and #2 acknowledged the aforementioned room were not ready for inspection and residents.
Plan of Correction:	I. The Maintenance Director put all AC Units back together on 9/30/21. Maintenance Director to perform, with Administrator oversight, a monthly walk through in order to ensure that air conditioning units are in good repair, a. The Maintenance Director is in the process of putting the Ptac unit coverings in rooms C-1 and C-12 back together, to be completed by 10/8/2l. Maintenance Director will remove by10/8/21. Ptac unit coverings were removed for professional cleaning and vents were taped for the same. b. Maintenance Director, with Administrator oversight, to perform a monthly walk through is in order to ensure that Ptac unit coverings and ceiling vents are in good repair. b. The Maintenance Director cleaned the toilet bowl on 9/30/21. Maintenance Director to perform, with Administrator oversight, a monthly observation of all toilets in order to ensure cleanliness. 2(a). The facility's 96 hour food and water supplies will be removed from Bedroom #B-8 and stored appropriately by 10/4/21. Maintenance Director, with Administrator oversight, to perform monthly walk through of the building to ensure appropriate storage. 2(b). The decoration items and boxes in Bedroom #B-15 will he removed and stored appropriately by 10/4/21. Maintenance Director, with Administrator oversight, to perform monthly walk through of the building to ensure appropriate storage. 3. Administrator will ensure that pagers for Cottage B and C are properly connected to the call light system by 10/4/21. Maintenance Director, with Administrator oversight, to perform monthly spot checks of the call light system in order to ensure correct operation.