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: Sept. 20, 2023 and Oct. 24, 2023

Complaint Related: Yes

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An unannounced on-site Complaint inspection was conducted on 9-20-23 (Ar 9:13 a.m./Dep 14:20). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (09/19/2023) regarding allegations in the area of resident care and related services- physical abuse by staff. Number of residents present at the facility at the beginning of the inspection: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: observed 1 resident/victim on scu Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure that it reported to the regional licensing office within 24 hours any major incident that has negatively impacted or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 9-20-23 staff #1 stated the local agency visited the facility and was conducting an investigation of physical abuse involving resident #1 and facility staff members. 2. Staff #1 acknowledged not reporting this information to the licensing office.
Plan of Correction:	Community staff will make sure the regional licensing office and any other relevant agency will have any major incident that has negatively impacted or that threatens the life, health, safety, or welfare of any resident, reported to them within 24 hours as required by the licensing standards for the state of Virginia. Correction Date: 9/20/2023 and Ongoing
Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	8Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: 1. Resident #1?s record documented resident was prescribed Haloperidol, hospice nurse order dated 8-25-23. Resident record also noted Trazadone prescribed, physician order dated 8-3-23. The record did not include documentation of a treatment plan for these psychotropic medications. 2. Staff #1 acknowledged the aforementioned resident?s record did not include a treatment plan for all prescribed psychotropic medications.
Plan of Correction:	Community staff will ensure that all incoming as well as in-house residents will have a treatment plan for any psychotropic medications. All psychotropics will be documented on its own form with its own treatment plan. DON/Designee will conduct monthly audits to make sure all treatment plans are in place and updated as needed. Correction Date: 9/20/2023 and Monthly
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for a resident. Evidence: 1. On 9-20-23, resident #1?s physical examination dated 6-28-23 noted resident #1 was allergic to Hydralazine, HCTZ and Reserpine. The record noted resident was receiving hospice services from a local agency with skilled nursing, social worker, chaplain, aide and volunteer aid. These assessed needs were not documented on the resident?s ISP dated 6-23-23. 2. Staff #1 acknowledged these assessed needs were not documented on the resident?s ISP.
Plan of Correction:	Community will update ISPs to include all allergies and reactions to allergies. ISPs will be updated within 7 days of any changes needed by the DON/Designee. Community will document and update the ISPs to reflect any changes that pertains to any services provide by third party agencies for our residents. DON/Designee will make necessary changes to ISPs within 7-days DON/Designee will conduct an audit of the ISPs for accuracy and update as needed monthly for the next three months and then quarterly thereafter. Correction Date: 9/20/2023, Monthly for the next 3 months and then quarterly.
Standard #:	22VAC40-73-720-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s written do not resuscitate order (DNR) was included in the individualized service plan (ISP). Evidence: 1. On 9-20-23, resident #1?s record included a signed do not resuscitate order (DNR) dated 1-5-23. The individualized service plan (ISP) dated 6-23-23 noted the resident was a full code. 2. Staff #1 acknowledged the ISP did not include the resident?s assessed code status of DNR.
Plan of Correction:	Community will ensure all residents who are admitted and retained and have a written do not resuscitate order is included on the IPS upon admission or within 7-days of having a new order signed. DON/Designee will audit all lSPs of existing residents to ensure they are updated to include DNR status. Correction Date: 9/21/2023, and Ongoing