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: Feb. 29, 2024

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 on-site unannounced renewal inspection was conducted on 2-29-24 by two inspectors from the Peninsula Licensing Office (Ar 08:35 a.m./ Dep 17:35 p.m.). The facility census was 18. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection with the new administrator. An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-73-1140-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within the first month of employment, staff, other than the administrator and direct care staff, who will have contact with residents in the special care unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia. Evidence: 1. On 2-29-24, staff #5?s record did not include documentation of having received training on the nature and needs of residents with cognitive impairments due to dementia. This staff member was observed on 2-29-24 providing activities with the residents in the cognitive units. The staff record documented job description for dietary and housekeeping; staff?s date of hire noted as 7-17-23. 2. Staff #9 acknowledged the staff?s record did not have training in cognitive impairment.
Plan of Correction:	By April 1st, 2024, the Director of nursing will provide training for cognitive impairments due to dementia and will be updated in all employee?s business files. Staff # 5 file was updated March 1st with proper job description. A complete audit for job descriptions will be conducted by April 15th, 2024 in order to ensure job descriptions are compliant.
Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure that it complied with the blood glucose monitoring practices. Evidence: 1. On 2-29-24, a medication cart observation was conducted in building A, with staff #4. Resident #5?s glucometer instrument was not labeled. 2. Staff #4 acknowledged the resident?s glucometer was not labeled.
Plan of Correction:	On February 29th, 2024, the Director of Nursing at English Meadows Williamsburg labeled the glucometer instrument with resident?s name. Director of Nursing will monitor labeling of Glucometers, weekly, for the next 3 months and intermittently, moving forward, in order to prevent reoccurrence.
Standard #:	22VAC40-73-250-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility, submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 2-29-24, staff #2?s record did not have documentation of a risk assessment, documenting the absence of TB. The staff?s date of hire was noted as 2-13-24. 2. Staff #3?s record included a risk assessment dated 7-17-23 but it did not include documentation of who completed the assessment. 3. Staff #1 and #2 acknowledged the staffs? record did not include the TB risk assessment requirements.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-C
Description:	Based on observations and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, was posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. On 2-29-24, staff #2 and #5 were not able to locate the first aid/CPR posting in building C. 2. Staff #2 acknowledged the first aid/CPR listing was not posted.
Plan of Correction:	Administrator on March 1st posted a current CPR/first aide list for all the staff members to always have access to. The Director of Nursing will monitor the CPR list to make sure is updated, monthly, for the next 3 months and intermittently, moving forward, in order to ensure compliance.
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule included the names of all staff working each shift. Any absences, substitutions, or other changes shall be noted on the schedule. Evidence: 1. On 2-29-24, the facility assignment sheet/staff schedule noted only the first name of staff members scheduled to work. 2. Staff #1 acknowledged the written schedule did not include staff member?s hired names.
Plan of Correction:	Administrator on March 4th Posted a schedule/assignment sheet in all three cottages ready and available for the public and staff to have access to that doesn?t include staff hired names. The Director of Nursing will monitor the schedule/assignment sheets, weekly, for the next 3 months and intermittently, moving forward, to make sure that they?re posted and correct.
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule included the names of all staff working each shift. Any absences, substitutions, or other changes shall be noted on the schedule. Evidence: 1. On 2-29-24, the facility assignment sheet/staff schedule noted only the first name of staff members scheduled to work. 2. Staff #1 acknowledged the written schedule did not include staff member?s hired names.
Plan of Correction:	On March 1st the Administrator went through each staff member?s record and updated their (TB) screening form published by VA department of Health. The administrator will monitor all new hire charts, upon hire, for the next 3 months and intermittently, moving forward, in order to prevent reoccurrence.
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the posting of the name of the current on-site person in charge was in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 2-29-24, the licensing inspectors did not observe the staff-in charge (SIC) posted in an area in the facility that was conspicuous to the residents and the public. 2. There was no listing posted where visitors signed in located in Building B. The staff schedule with staff listing was observed on the desk in the medication room in building A and C. 3. Staff #1 and #2 acknowledged the SIC was not posted in an area for the residents and public?s view.
Plan of Correction:	On March 13th, 2024, resident #2 received an updated treatment plan for prescribed Psychotropic medication. On March 11th, 2024, resident #1 received update fall risks to her chart. The Director of Nursing will monitor all charts to make sure that all fall risk is up to date, bi-weekly, for the next 3 months and intermittently, moving forward, in order to ensure compliance.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with specific conditions or care needs. Evidence: 1. On 2-29-24, resident #2?s record included documentation for Lorazepam following a hospital stay from 2-17-23 to 2-23-24. The record did not have a treatment plan for the prescribed psychotropic medication. 2. Staff #1 acknowledged the aforementioned resident?s record did not have a treatment plan for the prescribed psychotropic medication.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. On 2-29-24, resident #1?s record noted falls on 1-12-24, 2-9-24, 2-9-24, 2-13-24 and 2-17-24. The resident?s record did not include a fall risk review and or updated fall risk assessment after each fall. The record included a fall risk assessment dated 5-9-23. 2. Staff #1 acknowledged the aforementioned resident?s record did not include a fall risk review following the noted falls.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-A
Description:	Based on record reviewed, the facility failed to ensure it ascertained, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days and document in the resident?s record that this was ascertained and the date the information was obtained. Evidence: 1. On 2-29-24, resident #2?s record did not include documentation of a sex offender report. The resident?s date of admit noted as 2-7-24. 2. Staff #1 acknowledged the resident?s record did not include documentation of a sex offender document prior to admission.
Plan of Correction:	On February 29th, 2024, resident #2 sex offender documentation was run. Administrator will make sure that all residents are checked for sexual offender status upon admission and yearly. Administrator to monitor new admissions, moving forward, as well as ensure current residents have a sex offender registry check on file in order to ensure compliance.
Standard #:	22VAC40-73-450-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan of care (PPC) developed included all requirements. Evidence: 1. On 2-29-24, resident #2?s preliminary plan of care developed by facility representative #10 on 1-23-24 did not include a written description of what services will be provided to address identified needs, who will provide them, when and where the services will be provided, the expected outcome and time frame for expected outcomes. 2. Staff #1 and #9 acknowledged the aforementioned resident?s plan of care did not address the plan?s requirements.
Plan of Correction:	As of February 29th, 2024, English Meadows will not be using the preliminary care plan and will initiate the ISP 7 days prior to Admission. The Director and Nursing and Administrator will make sure that all ISP are done upon admission within 7 days, moving forward. A complete audit will be conducted by April 1, 2024 to ensure all ISPs are in place in order to ensure compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 2-29-24, resident #3?s uniformed assessment instrument (UAI) dated 2-21-24 noted dressing need assessed as human help/physical assistance (hh/pa). The individualized service plan (ISP) noted dressing needs as human- mechanical (hh/mh); resident requires one person staff assistance. The plan did not include the mechanical device to assist with dressing. Toileting need assessed as human help/physical assistance/mechanical help. The ISP noted toileting need as mechanical assistance; services noted use of handrails and raised toilet seat and staff assistance. Transferring need assessed as hh/pa. The ISP noted transferring as human- mechanical assistance; services noted resident requires physical assistance of one staff- no mechanical device noted. 2. Staff #9 acknowledged the aforementioned resident?s assessed needs and ISP documentation did not agree.
Plan of Correction:	On March 4th Resident #3 UAI and ISP were updated so that they could match. The Director of Nursing will make sure that all UAI and ISP are matching moving forward. A complete audit will be conducted in regard to UAIs/ISPs by April 1st, 2024 in order to ensure compliance.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the posted meals and snack menu for the current week was dated and included snacks. Evidence: 1. On 2-29-24, the posted menu in building A was not dated and did not include a listing of snacks. 2. Staff #4 acknowledged the menu posted was not dated and did not include a listing of snacks.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-720-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a written order for Do Not Resuscitate (DNR) was written by the resident?s attending physician. Evidence: 1. On 2-29-24, resident #2?s preliminary plan of care dated 1-23-24 noted the resident?s code status as DNR. The record did not include documentation of a signed DNR from a physician. 2. Staff #1 acknowledged the aforementioned resident?s service plan noted resident?s code status as a DNR but the record did not have a signed DNR order.
Plan of Correction:	On March 11th, 2024, Resident #2 file was updated with signed DNR and POA. The administrator will make sure that all new admissions will provide facility Code status and POA upon arrival to facility, moving forward. A complete audit of Code Status will be conducted by April 1st, 2024 in order to ensure compliance.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items. Evidence: 1. On 2-29-24, the first aid kit in building A did not include a flashlight, extra batteries, trash bag, and thermometer. 2. Staff #4 acknowledged the first aid kit did not include all required items.
Plan of Correction:	March 1st, 2024, the first aid kit in building A received a flashlight with extra batteries, trash bags and thermometer. The maintenance director will monitor the first aid kit for each month, moving forward, to make sure that it?s properly stocked.
Standard #:	22VAC40-73-990-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure at least every six months, all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. On 2-29-24, the facility documentation of the resident emergency was last dated June 2023. 2. Staff #1 acknowledged; the resident emergency was not conducted every six months as required.
Plan of Correction:	A resident emergency was updated with a more recent event that occurred on 1/2/2024.The maintenance director will make sure that resident emergency is updated within the next 6 months and the Administrator will monitor for compliance, moving forward.