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: April 8, 2022

Complaint Related: Yes

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The licensing inspector conducted an unannounced complaint inspection on 4-8-22 in response to a complaint that was received by the licensing office on 2-24-22. Resident records reviewed, medication cart reviewed and staff interviews regarding allegations of resident medication being given to another resident because resident's medication was not available and the staff who administered the medication was not medication certified also alleged insufficient staff on duty. The information gathered during the investigation does not support the allegation, so the complaint is determined to be invalid. There were other non complaint violations cited. 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 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days (4-30-2022)

Violations:

Standard #:	22VAC40-73-1110-B
Complaint related:	No
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 two of three residents. Evidence: 1. Resident #1?s record did not include documentation of an annual assessment for continued placement in the safe, secure unit. The resident?s date of admission was documented 1-15-21 (10-6-21-English Meadows) and 11-16-21 by the physician. The record did not include documentation of the facility?s assessment of continued placement by the administrator or designee. 2. Resident #2?s record did not include documentation of an annual assessment for continued placement. The resident?s date of admission was documented as 3-12-20. The last documented continued assessment was dated 10-28-21 by the physician. There was no documentation of continued review by the administrator or designee. 3. Staff #1 acknowledged the aforementioned residents? record did not include documentation of assessment for continued placement in the facility?s safe, secure unit.
Plan of Correction:	1.A complete audit will be conducted on all current residents to ensure compliance of appropriateness of continued residence in special care unit for all residents that have resided at English Meadow 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 #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the communication log book was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. On 4-8-22, the inspector inquired the date resident #1 was sent to the hospital and what was the situation. A review of resident?s nursing notes (progress notes) did not have documentation of the resident?s transfer. A review of the facility?s communication log book did not have documentation of the resident?s transfer. A check of the resident?s March 2022 medication administration record (MAR) noted resident was out of the facility on the evening of March 17, 2022 and had not returned as of the day of the inspection, 4-8-22. 2. Staff #1 acknowledged the facility staff was not documenting information in the facility?s communication log book as required.
Plan of Correction:	1. Facility has begun utilizing the 24 hour communication log. 2. Nursing staff will sign the 24 hour communication log every day prior to their shift to ensure it has been read. Nursing staff to document any concerns/issues on 24 hour report long. 3. Administrator/designee will receive a copy of 24 hour report every morning
Standard #:	22VAC40-73-310-H
Complaint related:	No
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 one of three residents. Evidence: 1. Resident #3?s March 2022 medication administration record (MAR) documented resident prescribed Lorazepam. The resident?s record did not include a signed and dated psychotropic treatment plan. 2. On 4-8-22 during the initial exit meeting staff #1 acknowledged facility did not have psychotropic treatment plan for the aforementioned resident.
Plan of Correction:	1. A complete 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.Resident #3 was discharged from the facility 4/20/2022 3. MARs will be reviewed at random monthly for 3 months and intermittently thereafter
Standard #:	22VAC40-73-380-B
Complaint related:	No
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 three 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 3-9-22. 2. The resident?s individualized service plan (ISP) dated 4-6-22 documented resident code status as ?DNR?. 3. On 4-8-22 during the initial exit meeting staff #1 acknowledged the resident?s personal and social data sheet documented ?Full Code? status and the record included a signed and dated ?DNR? document.
Plan of Correction:	1.Resident #3 personal social data was updated. all other resident records were audited to ensure personal and social data were correct. Executive Director/DON/Designee will ensure all personal and social data is completed and correct at the time of admission/ 2.DON?Designee will audit all new admissions to ensure personal and social data are in compliance with standards. 3.Executive Director/DON/Designee will audit 5 resident charts monthly for two months and intermittently thereafter to ensure compliance 4.Resident #3 was discharged from the facility on 4/20/22. Business file was closed accordingly.
Standard #:	22VAC40-73-450-F
Complaint related:	No
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 two of three residents. Evidence: 1. Resident #1?s record documented resident?s uniformed assessment instrument (UAI) was dated 1-15-22. The individualized service plan (ISP) was dated 5-11-21 with a review date of 2-15-22. The updated assessed needs were not documented on the ISP dated 5-11-21. 2. Resident 2?s record documented resident?s UAI was dated 3-8-22. The ISP was dated 5-11-21 with a review date of 3-9-22. 3. Staff #1 acknowledged the aforementioned residents? ISPs were not updated.
Plan of Correction:	1.A complete audit will be conducted by administrator/designee on all UAI/ISPs. 2.Resident number #1 and resident #2 ISP and UAI were reviewed and updated by DON/Designee on 4/18/22 3.ISPs will be reviewed at random or upon any significant change monthly for 3 months and intermittently thereafter.