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: March 22, 2022 and March 31, 2022

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted on 3-22-22 (ar: 7:45 a.m/dep 3:45 p.m.) The facility census was 13. The administrator was not present. The manager on duty was present and assisted the inspector with the renewal inspection. The breakfast meal was observed, morning activity, medication observation was conducted, staff and resident records were reviewed in addition to emergency preparedness documentation. An exit was conducted with the manager on duty. A final exit was conducted with the administrator and director on nursing on 3-31-22. The acknowledgement form was sent via email. Please complete the columns for "description of action to be taken: and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendars of receipt. If you have any questions, contact the licensing inspector at (757) 439-6815. Plan of correction is due by 4-21-22..

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the approval of one of the individuals in the order of priority. The written approval shall be retained in the resident?s file. Evidence: 1. Resident #2?s record did not include documentation of the written approval of the individual who was authorized according to the order of priority to give approval for the resident to be placed in the safe, secure unit. 2. On 3-22-22, staff #3 acknowledged the resident?s record did not include the written approval from the order of priority prior to placement in the safe, secure unit. 3. On 3-31-22 during the final exit meeting, staff #1 and #2 acknowledged that the aforementioned resident?s record did not have documentation of family?s approval for placement in the record.
Plan of Correction:	1.Executive Director or Designee will complete current documentation of determination for resident #2 by 4/8/2022. 2.The administrator or designee will audit 5 random resident records for documentation of determination monthly for two months and intermittently moving forward to ensure appropriate placement in the special care unit has been documented. 3.The administrator or designee will review all new resident files prior to day of move in to ensure the determination is completed and in the new resident record.
Standard #:	22VAC40-73-1110-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to admitting a resident with serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident?s file. Evidence: 1. Resident #2?s record did not contain documentation of the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. Resident #1?s date of admission was documented as 10-12-21. 2. On 3-22-22, staff #3 acknowledged the record did not include the administrator?s documentation of placement in the special care unit prior to admission. 3. On 3-31-22 during the final exit meeting, staff #1 and #2 acknowledged the aforementioned resident?s record did not include documentation of the licensee/ administrator?s determination of placement prior to placement.
Plan of Correction:	1.The Executive Director/Director of Nursing will conduct a review to ensure residents admitted to the EM-LH within the last six months have the appropriate documentation in their record reflecting their determination and justification for placement into the EM-LH. 2.The Executive Director and/or designee will review a new admissions Approval for Placement In Special Care Unit DSS Form 032-05-0082-03-eng prior to admission to ensure determination and justification are present on the form. 3. Charts will be reviewed by DON/Designee quarterly for 6 months and intermittently thereafter.
Standard #:	22VAC40-73-1110-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it performed a review of the resident?s appropriateness for continued placement in the special care unit (SCU) for one of four residents. Evidence: 1. Resident #1?s record did not include documentation of an appropriateness of placement six months after placement of the resident in the safe, secure environment (SCU). The record also did not include an annual assessment for continued placement. The resident?s date of admission was documented as 7-14-20. 2. On 3-22-22 staff #3 acknowledged, the document was not in the resident?s record. 3. On 3-31-22 during the final exit meeting, staff #1 and #2 acknowledged the aforementioned resident?s record did not have documentation of the six month nor annual review of appropriateness for continued placement in the scu.
Plan of Correction:	1.A complete audit will be conducted on all current residents to ensure compliance the review of appropriateness of continued residence in special care unit for all residents that have resided at English Meadows for 6 months or more. 2. To ensure continued compliance, the executive director will complete random audits on new admissions to ensure proper approval documentation is in place by administrator, physician and family. 3. Random audits will be completed quarterly and intermittently thereafter.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for three of four residents. Evidence: 1. Resident #2?s March 2022 medication administration record (MAR) and signed Physician?s Order Summary (POS) dated 3-10-22 documented resident prescribed Zyprexa, Trazadone and Clonazepam The resident?s record did not include a signed and dated psychotropic treatment plan. 2. Resident #3?s March 2022 MAR and POS dated 3-10-22 documented resident prescribed Seroquel and Zoloft. The resident also prescribed Lorazepam. The resident?s record did not include a signed and dated psychotropic treatment plan. 3. Resident #4?s March 2022 MAR and POS dated 3-10-22 documented resident is prescribed Fluoxetine. The resident?s record did not include a signed and dated psychotropic treatment plan. 4. On 3-22-22 during the initial exit meeting staff #3 acknowledged facility did not have psychotropic treatment plans for the aforementioned residents. 5. On 3-31-22 during an exit meeting with staff #1 and #2, staff acknowledged the aforementioned residents? record did not have documentation of a treatment plan for the aforementioned psychotropic medications.
Plan of Correction:	1.A 100% audit of the MARs will be conducted by the DON/designee to ensure a treatment plan is in place for psychotropic medications signed and dated. All findings will be reported to residents provider. 2. The administrator will provide additional education to the nursing staff regarding psychotropic medications and treatment plans being completed once received. 3.MARs will be reviewed quarterly and intermittently thereafter.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the information in the resident?s personal and social data document was kept current for one of four residents. Evidence: 1. Resident #3?s social data form documented resident preference in the event of cardiac or respiratory arrest was documented as full code. The resident?s record included a copy of a signed Do Not Resuscitate (DNR) document, signed and dated by the physician on 2-9-22. 2. The resident?s individualized service plans (ISPs) dated 3-29-21 and 8-25-21 documented resident code status as ?DNR?. 3. On 3-22-22 during the initial exit meeting staff #3 acknowledged the resident?s personal and social data sheet documented ?Full Code? status and the record included a signed and dated ?DNR? document. 4. On 3-31-22 during the final exit meeting with staff #1 and #2, staff acknowledged the aforementioned resident?s personal social data document was not kept current.
Plan of Correction:	1.Resident #3 personal social data was updated. All other resident records were checked to ensure personal and social data was correct. Executive 2. Director of Nursing will audit all new admissions to ensure the personal and social data are completed and correct at the time of admission also ensuring that updates are made to the documented personal and social data whenever there are changes. 3. Executive Director or Assistant Executive Director will audit 5 resident charts per month to ensure ongoing compliance.
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a resident?s uniformed assessment instrument (UAI) was completed annually and utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 3-22-22 during a review of resident #3?s record, there was no uniformed assessment instrument (UAI) in the record. The resident?s date of admission was document as 5-23-19. 2. Staff #3 acknowledged the record did not include an annual or reassessed UAI. 3. On 3-31-22, during the final exit meeting with staff #1 and #2, staff acknowledged the aforementioned resident?s record did not include an annual or reassessed UAI.
Plan of Correction:	Director of Nursing to review and update the resident's uniform assessment instrument. Director of Nursing will audit resident's charts to ensure that all required in-formation is updated on a monthly basis and intermittently thereafter
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) for three of four residents included all assessed needs. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 7-14-21 documented toileting need as human help/physical assistance. The resident?s individualized service plan (ISP) dated 5-12-21 documented resident uses a walker during toileting for safety. The resident is assessed as incontinent for bowel and bladder; the ISP did not document the residents? need for adult depends. 2. Resident #?s2 UAI dated 10-5-21 documented toileting need assessed as mechanical help/physical assistance; the ISP did not document what the mechanical need was. 3. Resident #3?s ISP dated 5-21-21 documented dressing need as mechanical help/ physical assistance; the ISP did not document what the mechanical need was. 4. Resident #4?s UAI dated 3-17-22 documented resident?s behavior pattern as appropriate; the ISP dated 2-17-22 documented resident wanders. 5. On 3-22-22 staff #3 acknowledged the residents ISPs did not document the assessed needs. 6. On 3-31-22 during the final exit with staff #1 and #2, staff acknowledged the aforementioned residents? ISPs did not include all assessed needs.
Plan of Correction:	1. The Administrator will make sure all needs identified from the physical form and the UAI are documented and addressed on the resident's ISP. 2. All records will be randomly audited quarterly for the next 6 months by the ED/DON and reviewed intermittently thereafter.
Standard #:	22VAC40-73-450-D
Description:	Based record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. Resident #3?s record included information from an agency providing hospice services 12-14-21. This information was not documented on the resident?s ISP dated 5-21-21. 2. On 3-22-22, staff #3 acknowledged resident?s ISP did not include hospice care services. 3. On 3-31-22, during the final exit meeting with staff #1 and #2, staff acknowledged the aforementioned resident?s ISP did not include hospice services being received.
Plan of Correction:	1. The ISP for resident has been updated to show the specific services that hospice provides. 2. Reeducation will be conducted by administrator for nursing staff on updating ISP for changes related to care. 3. A complete audit will be completed by Director of Nursing/designee to ensure that all residents that receive hospice services are listed on the ISP. 4. ISPs will be randomly audited quarterly and intermittently thereafter.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes for three of four residents. Evidence: 1. Resident #2?s record documented resident received occupational therapy (OT) services on 11-7-21 and 11-20-21. These services were not documented on the ISP and no dated of services end date. Resident?s record also documented physical therapy (PT) evaluation 10-15-21, services on 10-19-21, 10-21-21, 10-26-21, 10-27-21, 11-2-21, 11-3-21, 11-8-21 and discontinued on 11-9-21. This service was not documented on the ISP. 2. Resident #3?s record document resident received physical therapy (PT) services on 10-14-21 (evaluation), 10-19-21, 10-21-21, 10-26-21, 10-27-21, 11-02-21 and 11-4-21 services discontinued. This service was not documented on the ISP dated 5-21-21. 3. Resident #4?s record documents resident receive physical therapy (PT) services on 3-9-21, 3-14-21, 3-18-21, and 3-21-22. The service was not documented on the ISP and there was no end date of services on the ISP dated 2-17-22. 4. On 3-22-22 staff #3 acknowledged the residents? ISP did not include the resident?s change in condition and services being provided. 5. On 3-31-22 during the final exit meeting staff #1 and #2 acknowledged the aforementioned residents? ISP did not document the residents? change in condition and services need.
Plan of Correction:	1.Resident number 2,3, and 4 ISPs will be reviewed by DON/ED Designee by 4/22/22 2.All ISP certified staff will review the ISP training manual as a reeducation. 3.The ED/Designee will complete a 100% audit of charts for the thorough completion of the ISP. 4.ISPs will be audited monthly at random to ensure correctness
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all of the required information for one of four residents. Evidence: 1. On 3-22-22, during the medication pass observation with staff #4, resident #2?s March medication administration record (MAR) did not include diagnosis, condition, or specific indications for administering the following drug and or supplement: (a) Duloxetine, (b) Zyprexa, and (c) Trazadone. 2. On 3-22-22 staff #3 and #4 acknowledged the resident?s MAR did not include the diagnosis. 3. On 3-31-22 during the final exit meeting with staff #1 and #2, staff acknowledged the aforementioned resident?s MAR did not include the diagnosis for the drugs prescribed.
Plan of Correction:	1. A 100% audit of the MARs will be conducted by the administrator/director of nurslng//deslgnee to ensure MAR/POS includes diagnosis, condition, or specific indications for administering specific medication. 2. All findings will be reported to the residents provider as well as the QA committee for analysis and recommendation. 3.The adminlstrator/deslgnee will provide additional education for the nursing staff regarding medication management and record keeping. 4. The administrator /director of nursing will conduct a monthly audit of all medication administration records and physician order sheets to ensure the records include all required information. All completed actions will be submitted to the QA committee for analysis and recommendation.