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 23, 2023 , April 11, 2023 and April 27, 2023

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint An unannounced monitoring inspection was conducted on 3-23-23 (ar 10:10 a.m/dep 1:30 p.m): The Acknowledgement of Inspection form was signed and dated by the administrator. The acknowledgement was also provided following the virtual preliminary meeting and final exit meeting. A complaint was received by VDSS Division of Licensing on 2-27-23, 3-6-23, 3-9-23 and 3-13-23 regarding allegations in the areas of staffing and supervision and resident care and related services on the safe, secure unit and assisted living unit. Number of residents present at the facility at the beginning of the inspection: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: ceiling in common area of scu Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings, The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulations. Evidence: 1. On 3-23-23, during a complaint inspection, a request for the facility?s staffing sheeting and staff pay record was made from the administrator. A review of documents revealed there was not sufficient staff in the facility to provide services to the residents in the assisted living and safe, secure unit as alleged in the complaints. 2. According to the complaint, there were residents in the facility who required two- and three-person assistance. Staff #1 stated and provided the names of four residents who were assessed as two-person assist and one resident who was assessed as three-person assist, resident #3. 3. According to the facility?s ?Time Detail Report? and staffing sheeting, on 2-25-23 there were two staff on duty on the 3p to 11p and 11p to 7a shift. On 2-26-23, 11p to 7a shift there were two staff on duty. On 3-6-23 on the 3p to 11p shift, there was one staff on shift from 3:45p to 5:30p and two staff on 11p to 7a shift. On 3-11-23 there were two staff on 3p to 11p shift.
Plan of Correction:	The community?s executive director or designee will make sure the community have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with state licensing standards. Correction Date: 4/22/23 and ongoing
Standard #:	22VAC40-73-450-G
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed and filed in the resident?s record. Evidence: 1. On 3-23-23 during a complaint inspection, resident #1 and #2?s individualized service plan (ISP) was not in the resident?s record and available for review. Resident #1?s date of admit noted as 12-6-22. Resident #2?s date of admit noted as 2-23-23.
Plan of Correction:	Admin and Don will make sure resident?s preliminary care plan is completed upon admission and a comprehensive care plan will be completed 30-days following the preliminary care plan as stated in the licensing standards. Admin, DON or designee will audit resident?s ISP?s Quarterly for six months, annually and thereafter when changes occurs. ISPs will be updated within 30-days of any changes that needs to be added or discontinued. All current residents ISPs have been completed and are up to date as of 5/1/2023. Correction Date: 5/1/23 and ongoing
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observations and staff interviewed, the facility failed to maintain the facility in good condition. Evidence: 1. On 3-23-23 during a complaint allegation of the facility?s ceiling in the common area of the safe, secure unit leaking an observation was conducted of the room. The left area of the ceiling in the common area of the safe, secure unit, near the medication room was observed to have a very large wet spot area. According to staff #2, the wet spot observed by the inspector was due to the ceiling leak that had occurred.
Plan of Correction:	Community will provide maintenance and repair to building and grounds as needed to ensure the interior and exterior of all buildings are maintained in good repair and kept clean and free of rubbish, as stated in the licensing standards. Repairs were completed on 4/8/23 and will be maintained going forward by community maintenance director. Correction Date: 4/8/23