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: April 8, 2024 and April 18, 2024

Complaint Related: Yes

Areas Reviewed:

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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site inspection conducted on 4-8-24 (Ar 09:35 Dep 13:00, 4-18-24 (AR 10:32/ Dep 13:00). The census on 4-8-24 was 19. 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 4-2-24 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: Number of interviews conducted with staff: 4 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 allegation 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 #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule included any absences, substitutions or any other changes was noted on the schedule. Evidence: 1.On 4-8-24, a review of the facility?s schedule for March 30, 2024, and March 31, 2024, the staff noted on the schedule did not work. The schedule was not updated to reflect the changes. Staff #4 noted on schedule for 7-3 a.m. shift on March 30, 2024. Staff stated not working on March 30, 2024. 2. Staff #1 acknowledged the scheduled was not updated to reflect substitutions or changes to schedule.
Plan of Correction:	As of May 1st, 2024, any changes made to schedule are to be approved by the Director of Nursing or the Administrator and the changes will be hand written on the next business day
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, the person who developed the plan and by the resident or the legal representative. Evidence: 1.On 4-8-24, resident #1?s record was reviewed with staff #1. The ISP dated 3-6-24 was not signed and dated by the develop and there was no signature of the plan by the resident and/or legal representative.
Plan of Correction:	As of May 1st, 2024, English Meadows will make sure that all patients ISPs are signed 30 days from the day of the admission.