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 22VAC40-80 COMPLAINT INVESTIGATION
Comments:
Type of inspection: Complaint
An on-site complaint inspection conducted on 1-12-24. The facility census was 24. 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 1-8-24 regarding allegations in the resident care and related services and staff and supervision.
Number of residents present at the facility at the beginning of the inspection: 24 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: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 8 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
Based on observation and staff interviewed, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident, except under staff supervision.
Evidence: 1. On 1-12-24 during a tour of the facility, the housekeeping cart in Building A, safe, secure unit, was observed unsupervised and unlocked. A spray bottled label ?bleach?, a bottle labeled creme deodorizing cleanser, with the power of bleach and a bottle labeled smoke and odor eliminator were observed on in a bucket on the lower stand portion of the housekeeping cart. The door to the housekeeping cart was also observed to be unlocked. 2. Staff #1 and #7 acknowledged, the unsupervised and unlocked housekeeping cart contained materials harmful for residents on the safe, secure unit.
Plan of Correction:
Housekeeper was educated on the proper storage of chemicals she was made aware that she is supposed to keep her chemicals locked in her cart. Administrator/Designee to perform housekeeping cart security audits 1x per week for 30 days to prevent future occurrences. Date of Correction 2/20/24
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 1-12-24, during a complaint inspection, resident #1?s progress notes documented on 1-1-24 at 11:18 ??resident sent to hospital due to worsening condition from bruising on left temple, swollen left eye, and nose looked sideways?. resident started to seem weak and was having difficulty standing and sitting up?. 2. The facility incident report noted on 1-1-24, staff document sending resident to a local hospital, resident thought to have had a fall. There was no incident report, the resident?s POA was contacted, who was not notified of a fall which led to resident having a bruised temple, eye swollen shut and nose was sideways, resident blood pressure (BP) 255/104. Document noted resident did not fall but ran into the activity door on overnight shift 12/30/23. There is no documentation in the record of resident being sent for medical treatment until 1-1-24. 3. The facility did not report the incident to the licensing department. The incident was reported to the licensing department on 1-8-24. 4. Staff #1 and #2 acknowledged not reporting an incident that negatively affected or that threaten the life, health, safety, or welfare of a resident.
Plan of Correction:
The Administrator or Director of Nursing of English Meadows Williamsburg will ensure that reporting of any major incident is reported to VDSS LI is completed within 24hrs moving forward. Date correction was 2/20/24
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 includes the names of all staff working each shift. Any absences, substitutions, or other changes shall be noted on the schedule.
Evidence: 1. On 1-12-24, the facility assignment sheets dated 12-28-23 to 1-11-24 did not include, the full name of the individuals working. The documents noted first names only on the ?Daily Staffing Assignment Sheet?. 2. The facility?s time sheet provided did not match the names and shifts of the names on the ?Daily Staffing Assignment Sheet?. 3. The ?Daily Staffing Assignment Sheet? noted one staff working the safe, secure units (A and C) seven times from 12-28-23 to 1-11-24. 4. Staff acknowledged the facility did not ensure the written work schedule included all required information.
Plan of Correction:
The Administrator or Director of Nursing of English Meadows Williamsburg will monitor the schedule daily moving forward to include assignment sheets to ensure completion and accuracy, absences or any substitutions will be made by the Director of Nursing as needed on the assignment sheet. Date of Correction was 2/20/24.
Standard #:
22VAC40-73-310-B
Complaint related:
No
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure it had documentation of an interview between the administrator or a designee responsible for admission and retention decisions.
Evidence: 1. Resident #1?s record did not include documentation of an interview between the administrator or a designee responsible for admission and retention. 2. Staff #1 and #2 acknowledged the resident?s record did not include documentation of an interview.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-440-A
Complaint related:
No
Description:
facility was assessed using the uniformed assessment (UAI) instrument prior to admission.
Evidence: 1. On 1-12-24, resident #1?s record did not include documentation of a UAI prior to admission, nor during the time of admission. The resident?s date of admit noted as 11-17-23. 2. Staff #1 and #2 acknowledged the resident?s record did not include a UAI.
Plan of Correction:
Administrator/DON to utilize checklist for admission moving forward to ensure that UAI?s are completed prior to 30-day period. Resident #1 UAI was completed by administrator if 2/20/24.
Standard #:
22VAC40-73-450-A
Complaint related:
No
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan of care was developed to address the basic needs of the resident that adequately protects the health, safety, and welfare.
Evidence: 1. On 1-12-24, resident #1?s preliminary plan of care document did not address the resident?s needs, what services staff will provide, when, where and review or outcome dates. 2. Resident #2?s preliminary plan of care did not address the resident?s needs, what services staff will provide, when, where and review or outcome dates. 3. Staff #1 and #2 acknowledged the residents? preliminary plan of care did not address resident?s needs.
Plan of Correction:
Administrator/DON to utilize checklist for admission moving forward to ensure that ISP are completed within 30 days of admission resident #1 ISP was completed by administrator of 2/20/24.
Standard #:
22VAC40-73-450-C
Complaint related:
No
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission.
Evidence: 1. On 1-12-24, resident #1?s record did not include a comprehensive individualized service plan. The resident?s date of admit was noted as 11-17-23. 2. Resident #2?s record did not include a comprehensive individualized service plan. The resident?s date of admit was noted as 10-31-23. 3. Staff #1 and #2 acknowledged the residents? record did not include a comprehensive individualized service plan.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-640-A
Complaint related:
No
Description:
Based on document reviewed and staff interviewed, the facility failed to ensure medication ordered was filled in a timely manner.
Evidence: 1. On 1-12-24, resident #1?s January 2024 medication administration record (MAR) noted resident to be administered Seroquel 100 mg tablet by mouth at bedtime for psychotic disorder. The record included a prescriber?s order dated 12-7-23 and 12-14-23. This labeled medication was not on the medication cart. The medication of the cart was labeled 50 mg tab three times a day. 2. Staff #1 and #3 acknowledged the Seroquel noted on the resident?s MAR was not available and labeled on the cart.
Plan of Correction:
Not available online. Contact Inspector for more information.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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