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: July 11, 2022 and July 19, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring An unannounced focus inspection was conducted on 7-11-22 (AR 09:00/ Dep 14:20). The facility census was 12. The Acknowledgement of Inspection form was sent via email to the Administrator for signature. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-A
Description:
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 #:	22VAC40-73-450-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 6-10-22 documented no behaviors. The ISP dated 6-8-22 documented resident wandering/exit seeking weekly or more and staff to redirect and reorient resident as needed. 2. Resident #2?s UAI dated 5-23-22 documented resident?s behavior as appropriate. The ISP dated 5-23-22 documented resident?s behavior as appropriate and to redirect as needed. The ISP also documented resident wanders and exit seeking, services to be provided for the mobility need. 3. Resident #4?s UAI dated 5-2-22 documented wheeling not performed without providing documentation as to who and how services would be performed. 4. On 7-11-22 staff #1 and #2 acknowledged the aforementioned residents? ISPs did not document the 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.