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 1, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced renewal inspection conducted on 2-8-23 (ar 11:00 a.m./dep 18:00 p.m). Day 2 2-9-23 (ar 06:45 a.m/dep 09:25 a.m.) The census on day 1 was 18. A tour of the facility was conducted, staff and residents records reviewed, emergency preparedness reviewed, lunch meal observed on day 1, breakfast meal and adl care observed on day 2; medication pass observed on day 2. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A final exit meeting will be conducted. 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 a willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-380-B
Description:	Based on record review and staff interview, the facility failed to ensure the personal and social information required was kept updated for one of six residents. Evidence: 1. On 2-8-23, resident #1?s physical examination dated 10-17-22, physician progress note dated 1-12-23 and physician?s order sheet dated 1-12-23 documented the resident was allergic to Gemfibrozil, Lovastatin, Simvastatin, Atorvastatin, Cymbalta and Fenofibrate. These assessed needs were not on the resident?s personal and social data sheet. 2. Staff #1 acknowledged the resident?s personal and social data form was not updated.
Plan of Correction:	Community staff will make sure resident?s face sheets are updated as needed. Community staff will audit residents face sheets once a month for three months and then every quarter thereafter. Face sheets will be updated within 24-hours of any changes that needs to be added or discontinued. Correction Date: 3/20, 4/20, 5/20 then quarterly
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of six residents. Evidence: 1. On 2-8-23, resident #1?s uniformed assessment instrument (UAI) dated 10-22-22 documented dressing need assessed as physical assistance. The ISP dated 10-13-22 documented resident required ?no assistance?. Medication is assessed as being administered by facility staff on the UAI and ISP. The admitting physical examination dated 10-18-22 documented resident able to self-administer medications. The facility?s ?Self-Administration of Medication Observation? form dated 11-16-22 and 1-21-23 documented medications the resident was able to self-administer. The facility ?Provider Order Form? dated 1-19-23 documented resident ?Ok to self-administer medications except narcotics?. Medications that the resident can self-administer is not documented on the ISP. 2. Resident #2?s UAI dated 8-9-22 documented eating with supervision; the ISP dated 9-25-22 documented resident is ?Independent?. Stairclimbing assessed as mechanical help/physical assistance (mh/pa); the ISP documented supervision help. The UAI documented the resident?s behavior and orientation is appropriate and oriented; the ISP documented the resident is disoriented some spheres, some of the time-situation. The ISP also documented mobility, ?resident is confined to secure care unit due to wandering/exit seeking weekly or less?. The secure care unit need documented also documented resident has, ?serious cognitive impairment?unable to recognize danger?. The record did not include safe, secure assessment documents. The resident also received Speech Therapy services; discontinued services documentation dated 8-31-22. This service need was not on the ISP. 3. Resident #3?s record documented occupational therapy services: 11-4, 22, 11-6-22, 11-10-22, 1-5-23, 1-10-23 and 1-18-23. Physical therapy services: 11-2-22, 11-8-22, 11-9-22, discharge services on 12-19-22; services also on 1-3-23, 1-4-23, 1-9-23 and 1-20-23. 4. Resident #4?s UAI dated 9-11-22 documented feeding/eating need as mechanical help/supervision (mh/s). 5. Resident #5?s record documented resident receives mental health services from a local agency. This need is not documented on the ISP dated 5-20-22. 6. Staff #1 acknowledged the aforementioned residents? records did not include all assessed needs.
Plan of Correction:	Community will update ISPs to include all services provided to the residents through hospice. Community will audit the files of any residents who receive hospice services monthly for the next three months and then quarterly thereafter. Community will make sure that all services being provided are updated on the resident?s ISP and any changes will be documented within 24-hours. Correction Date: 3/20, 4/20, 5/20 then quarterly Community staff will audit all UAIs and ISPs to ensure they match monthly for the next three months, and quarterly thereafter. Any changes will be updated and corrected on both the UAI and ISP within 24-hours of the documented changes to address all assessed needs of the resident. These changes will include any services being provided by outside agencies such as the hospice or mental health providers. Correction Date: 3/20, 4/20, 5/20 then quarterly
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of six residents. Evidence: 1. On 2-8-23, resident #1?s uniformed assessment instrument (UAI) dated 10-22-22 documented dressing need assessed as physical assistance. The ISP dated 10-13-22 documented resident required ?no assistance?. Medication is assessed as being administered by facility staff on the UAI and ISP. The admitting physical examination dated 10-18-22 documented resident able to self-administer medications. The facility?s ?Self-Administration of Medication Observation? form dated 11-16-22 and 1-21-23 documented medications the resident was able to self-administer. The facility ?Provider Order Form? dated 1-19-23 documented resident ?Ok to self-administer medications except narcotics?. Medications that the resident can self-administer is not documented on the ISP. 2. Resident #2?s UAI dated 8-9-22 documented eating with supervision; the ISP dated 9-25-22 documented resident is ?Independent?. Stairclimbing assessed as mechanical help/physical assistance (mh/pa); the ISP documented supervision help. The UAI documented the resident?s behavior and orientation is appropriate and oriented; the ISP documented the resident is disoriented some spheres, some of the time-situation. The ISP also documented mobility, ?resident is confined to secure care unit due to wandering/exit seeking weekly or less?. The secure care unit need documented also documented resident has, ?serious cognitive impairment?unable to recognize danger?. The record did not include safe, secure assessment documents. The resident also received Speech Therapy services; discontinued services documentation dated 8-31-22. This service need was not on the ISP. 3. Resident #3?s record documented occupational therapy services: 11-4, 22, 11-6-22, 11-10-22, 1-5-23, 1-10-23 and 1-18-23. Physical therapy services: 11-2-22, 11-8-22, 11-9-22, discharge services on 12-19-22; services also on 1-3-23, 1-4-23, 1-9-23 and 1-20-23. 4. Resident #4?s UAI dated 9-11-22 documented feeding/eating need as mechanical help/supervision (mh/s). 5. Resident #5?s record documented resident receives mental health services from a local agency. This need is not documented on the ISP dated 5-20-22. 6. Staff #1 acknowledged the aforementioned residents? records did not include all assessed needs.
Plan of Correction:	Community staff will audit all ISPs for medication observation for all residents who are assessed to self-administer. Residents will be reassessed monthly for the next three months and quarterly thereafter to ensure the residents are able to safely self-administer their medications. ISPs will be updated to match physician orders when changes occur within 24-hours of the new order. Community will do a quarterly review of all physician orders and match them to the orders on the resident?s ISP. Correction Date: 3/20, 4/20, 5/20 then quarterly
Standard #:	22VAC40-73-450-D
Description:	Based on record review and staff interview, the facility failed to ensure when hospice care is provided to residents, the assisted living facility 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.On 2-8-23, resident #3?s record documented resident evaluation and treated for hospice services with a local agency on 1-26-23. The record also documented the following services to be received: skilled nursing, hospice aide, social worker and chaplain. 2. Resident #4?s record documented hospice services start of care dated 1-13-23 through 4-12-23. Services include skilled nursing, social worker, hospice aide and chaplain. 3. Staff #1 acknowledged the aforementioned residents? record did not include the hospice services.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-B
Description:	Based on observation and staff interview, the facility failed to ensure it have a motor vehicle that is used to transport residents and motor vehicle used for a field trip, there shall be a first aid kit on the vehicle that includes all the required items per 22VAC40-73-980-A of the regulation. Evidence: 1. On 2-8-23, a check of the facility?s first aid kit for the vehicle, the following items were missing: the thermometer, small flashlight and extra batteries, plastic bags, and blankets. 2. The first aid kit in the nursing station on the Lavender Cottage was missing the hand cleaner (waterless hand sanitizer or antiseptic towelettes). 3. Staff #5 and #10 acknowledged the first aid kits did not include all required items.
Plan of Correction:	Community will provide first aid kits throughout the community and in the community vehicles. First aid kits will be equipped with the necessary items as set forth in regulatory standards for assisted living facilities in the state of Virginia. Going forward community staff will conduct weekly audits of all first aid kits for missing and out of date items, missing items will be replaced as needed. Correction Date: 3/20, 4/20, 5/20 then quarterly