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 29, 2024 and April 8, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 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 Complaint Inspection was conducted on 3-29-24 (AR 11:41/dep 14:01). The facility census 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 3-14-24 regarding allegations in the 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: 1 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were valid. A violation notice was 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 #:	22VAC40-73-1100-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed the facility failed to ensure prior to placing a resident with serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval from someone noted in the order of priority per 22VAC40-73-1100 A. Evidence: 1. On 3-29-24, a review of resident #1?s record with staff #1, the record did not include documentation of someone noted in the order of priority as specified in subsection A, granting permission for resident #1 to be placed in a safe, secure environment (sse). 2. Staff #1 acknowledged the documents in the record did not include authorization from someone in the order of priority for the resident to be placed in the sse prior to be placed on 3-2-24.
Plan of Correction:	By June 15th, 2024, all residents? charts will be audited and updated to make sure that Approval for Placement forms are completed in accordance with VDSS standards. Administrator/Designee to ensure that Approval for Placement forms are completed by the date of admission.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 3-29-24, the inspector interviewed staff #1 regarding a complaint alleging resident #1 not having medication and the family receiving a call ?in the middle of the night? to bring residents medication to the facility. Staff confirmed that family was contacted to bring the resident?s medication to the facility the first night of admission (2-2-24). Staff #1 provided the inspector a copy of the facility?s-controlled drug record indicating the date the resident?s medication was received. The resident?s-controlled drug record documented the resident's Lorazepam 0.5 mg tablet was received by staff #2 on 2-3-24. 2. Staff # 2 was interviewed, staff stated resident #1?s medication was not available, and the resident was aggressive toward staff. The administrator was contacted, who instructed staff to contact the family who came a gave the resident medications. Staff did not know what medications as the family would not give the medication to staff. 3. Staff #3 was interviewed, staff stated resident #1 was aggressive, family was contact and came to the facility to help calm the resident. Staff not aware if medication was available. 4. Staff #1 and #2 acknowledged the resident was admitted on 3-2-24. The resident?s medication was not available to administer to the resident on the night of 3-2-24 when the resident was displaying negative behaviors on the unit. Family members were contacted and came to the facility sometime after midnight to assist with the resident?s behavior and brought resident?s medication.
Plan of Correction:	Administrator/Director of Nursing to monitor all new admission History and Physical medication lists to ensure that the orders are submitted to the pharmacy within a time frame that will ensure medication delivery on the day of admission. On May 1st, 2024, the medication administration policy has been reviewed and updated and the staff have been trained on the new policy.