Virginia DSS · Assisted Living Facility

English Meadows Abingdon Campus

📍 15089 Harmony Hills Lane, Abingdon, VA, 24211

ID 47918Two Year licenseActive
10
Inspections
On record
5
With violations
Visits that cited something
5
Clean visits
Nothing cited
15
Violations cited
Individual findings
13
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

English Meadows Abingdon Campus was inspected 10 times between April 5, 2022 and April 21, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 15 violations under 13 distinct standards. 3 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 9 of these 10 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
10/14/2027
Administrator
Anna Laura Henderson
Licensing inspector
Rebecca Berry
Inspector phone
(276) 608-3514
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

10

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

April 21, 2026Inspection0 violations
Inspection dates
04/21/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/21/2026, 10:03am to 10:58am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/15/2026 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 66 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: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 10, 2025Complaint survey4 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025, 3:30pm to 5:00pm 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 07/29/2025 regarding allegations in the area(s) of: Number of residents present at the facility at the beginning of the inspection: 71 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: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 6 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 the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-325-C
Based on a review of resident records, the facility failed to show documentation of an analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. According to documentation by the hospice nurse, facility staff notified hospice that resident #1, who met the criteria for assisted living care, rolled out of bed the morning of 06/20/2025.
  2. There was no documentation of an analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce risk of subsequent falls observed in the record for resident #1.
Plan of correction
All medication staff, nursing administration and administrator will be provided education by 10/03/2025 in regard to ensuring the completion of documentation of analysis of fall and interventions-initiated post fall. Admin/DON/Designee to perform incident report audit for individuals who have had a fall once per week for 3 months, then once per month for 3 months and intermittently going forward to ensure completion of incident reports to include fall analysis and intervention post falls. [SIC]
22VAC40-73-325-B
Based on a review of resident records and interview with staff, the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. According to documentation by the hospice nurse, facility staff notified hospice that resident #1 had rolled out of bed the morning of 06/20/2025.
  2. The most recent fall risk rating observed in the record for resident #1 was dated 04/01/2025.
  3. Per staff #7, a more recent fall risk rating was not completed for resident #1.
Plan of correction
Nursing administration staff and administrator were provided education on 10/01/2025 in regard to ensuring the review and completion of fall risk rating after a fall. Admin/DON/Designee to perform fall risk rating audit for individuals who have had a fall once per week for 3 months, then once per month for 3 months and intermittently going forward to ensure fall risk ratings are being completed / updated post falls. [SIC]
22VAC40-73-560-E
Based on a review of resident records, the facility failed to ensure all resident records shall be kept current.
Evidence
  1. According to documentation by the hospice nurse, facility staff notified hospice that resident #1 had rolled out of bed the morning of 06/20/2025, resulting in a nosebleed.
  2. Per hospice after hours visit notes, the hospice nurse arrived at the facility at 7:25am on 06/20/2025 to assess resident #1.
  3. There was no documentation observed in the record for resident #1 regarding this fall, including the notification made to hospice or the identification of the staff person who made the notification.
Plan of correction
All medication staff, nursing administration and administrator will be provided education by 10/03/2025 in regard to ensuring all resident records are kept current. Admin/DON/Designee to perform incident documentation audits once weekly for 3 months, then once monthly for 3 months and intermittently going forward to ensure resident record current with incident documentation. [SIC]
22VAC40-73-460-F
Based on a review of records, the facility failed to notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. The resident's record shall include documentation of the notification, including date, time, caller, and person or agency notified.
Evidence
  1. According to documentation by the hospice nurse, facility staff notified hospice that resident #1 had rolled out of bed the morning of 06/20/2025, resulting in a nosebleed.
  2. Per hospice after hours visit notes, the hospice nurse arrived at the facility at 7:25am on 06/20/2025 to assess resident #1.
  3. Per collateral #1 (next of kin), she was not notified by facility staff regarding a fall that occurred on 06/20/2025.
  4. There was no documentation observed in the record for resident #1 that facility staff notified collateral #1 regarding a fall 06/20/2025.
Plan of correction
All medication staff, nursing administration will be provided education by 10/03/2025 in regard to ensuring designated contact person notification and documentation of that notification. Admin/DON/Designee to perform audits of documentation of incidents to include notification to designated contact person once per week for 3 months, then once per month for 3 months, and intermittently going forward to ensure completion of fall documentation. [SIC]
September 10, 2025Inspection0 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025, 10:15am to 3:29pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Noon meal, activities Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 14, 2024Complaint survey0 violations
Inspection dates
08/14/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/13/2024, 12:55pm to 1:20pm and 08/14/2024, 1:07pm to 1:43pm 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 08/07/2024 regarding allegations in the area(s) of: Resident care and related services, food and nutrition. Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: n/a Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Kitchen and dining areas 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(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 13, 2024Inspection3 violations
Inspection dates
08/13/2024, 08/14/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/13/2024 9:30am to 3:04pm, 08/14/2024 9:30am to 2:05pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Noon meal, activities, medication pass Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-870-A
Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. In resident room #208, small dark spots/stains were observed on the carpet in the bedroom and living room.
  2. In resident room #207, dark streaks were observed on the carpet in the living area.
  3. In resident room #213, small particles of dirt/debris were observed on the floor in the kitchen in front of the sink and the refrigerator.
  4. In resident room #210, several small dark spots/stains were observed on the carpet at the entrance to the room and in the living area.
  5. On the second floor, several large dark stains were observed on the carpeting in the main part of the hallway.
  6. In resident room #218, several dark spots/stains and streaks were observed on the carpet in the area around the bed.
  7. In resident room #228, dark spots/stains were observed on the floor leading from the living area into the bedroom.
  8. In resident room #231, several dark spots/stains were observed on the carpet in the living area.
  9. In resident room #112, several small particles of dirt/debris were observed on the floor in the living area and in the area around the toilet in the bathroom.
  10. In resident room #101, particles of dirt/debris were observed on the floor near the bed in the room on the left when walking into the room.
  11. In resident room #135, there was a stain on the carpet under the dining table in the room on the left when walking into the room.
  12. In resident room #135, stains were observed on the carpet in the entryway, in front of the recliner, by the dining table and beside the bed.
  13. In resident room #134, several small stains were observed on the carpet in the entry way, living room and bedroom, and a dark line approximately 1-2 inches in diameter was observed running across the bathroom floor from entry to the wall behind the toilet.
  14. In resident room #126, small particles of dirt/debris were observed on the floor in the living room area around the recliner and table, and in the bathroom.
  15. In resident room #122, several white spots were observed on the floor in the kitchen in front of the refrigerator and cabinets, as well as several small dark spots.
Plan of correction
Maintenance, housekeeping, and management staff educated by 09/06/2024 on ensuring the interior of the building is maintained in good repair and kept clean and free of rubbish. Administrator/designee will conduct environmental cleaning checks to resident rooms 208, 207, 213, 210, 218, 228, 231, 112, 101, 135, 134, 126, and 122 once weekly for 3 weeks and then once monthly for 3 months to ensure compliance. [SIC]
22VAC40-73-890-B
Based on observations made during the tour of the building, the facility failed to ensure that all interior and exterior areas shall be adequately lighted for the safety and comfort of residents and staff.
Evidence
  1. In resident room #101, the light in the entryway was not working at the time of inspection.
Plan of correction
Maintenance, housekeeping, nursing and management staff educated by 09/06/2024 on ensuring all interior and exterior areas shall be adequately lighted for the safety and comfort of residents and staff. Administrator/designee will conduct checks to resident room 101 once weekly for 3 weeks and then once monthly for 3 months to ensure compliance. Light bulb was replaced on 8/14/2024. [SIC]
22VAC40-73-870-E
Based on observations made during the tour of the facility, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition.
Evidence
  1. In resident room #126, small particles of dirt/debris were observed on the shower floor, as well as a stain, light red in color, in the back right corner.
  2. In the same room, a ring was observed on the inside of the toilet bowl, as well as other dark spots.
Plan of correction
Maintenance, housekeeping, and management staff educated by 09/06/2024 on ensuring all furnishings, fixtures, and equipment are kept clean and in good repair and condition. Administrator/designee will conduct environmental checks to resident room 126 once weekly for 3 weeks and then once monthly for 3 months to ensure compliance. Room 126 was deep cleaned on 8/14/2024. [SIC]
December 18, 2023Complaint survey2 violations
Inspection dates
12/18/2023
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/18/2023, 2:35pm to 3:57pm 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 12/18/2023 regarding allegations in the area(s) of: Resident accommodations and related provisions. Number of residents present at the facility at the beginning of the inspection: 68 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: n/a Number of interviews conducted with residents: 1 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 the(allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-750-B
Based on observations made during a tour of the building, the facility failed to ensure bedrooms shall contain a separate bed with comfortable mattress, springs, and pillow for each resident.
Evidence
  1. During a visit to the facility on 12/18/2023, the licensing inspector observed no bed in the room for resident #1. There was a twin-size mattress on the floor of the room for resident #1.
  2. Per staff #1, she was notified by staff #2 during day shift on 12/17/2023 that the bed for resident #1 was broken and had been removed from the room.
  3. Per staff #2, she observed the bed to be broken at approximately 2:30pm on 12/17/2023. She removed the bed frame from the room and notified staff #1.
Plan of correction
Maintenance, nursing and management staff educated by 12/20/2023 on ensuring residents have the required furniture and it is in good condition. Staff to be educated on appropriate steps to take. Administrator/Designee will check resident #1’s bed once weekly for 3 weeks and then once monthly for 3 months to ensure compliance. Son brought in new bed frame on 12/18/2023. [SIC]
22VAC40-73-870-E
Based on observations made during a tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. Per staff #1, she was notified by staff #2 during day shift on 12/17/2023 that the bed for resident #1 was broken and was removed from the room.
  2. Per staff #2, she observed the bed to be broken at approximately 2:30pm on 12/17/2023. She reports the bed frame was bent in the middle.
  3. Approximately half of the surface of the mattress for resident #1 was observed to be covered in light brown stains.
Plan of correction
Maintenance, nursing and management staff educated by 12/20/2023 on ensuring residents have the required furniture and it is in good condition. Staff to be educated on appropriate steps to take. Care plan updated for resident removing bedding. Administrator/Designee will check resident #1’s bed once weekly for 3 weeks and then once monthly for 3 months to ensure compliance. Son brought in new bed frame on 12/18/2023. [SIC]
August 3, 2023Inspection2 violations
Inspection dates
08/03/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/03/2023, 9:40am to 2:49pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 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 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on a review of resident records, the facility failed to address all identified needs on the comprehensive Individualized Service Plan (ISP) for one of the nine resident files that were reviewed.
Evidence
  1. The Uniform Assessment Instrument (UAI) in the record for resident #5, dated 03/09/2023, identifies toileting, mechanical and human help, supervision, as an area in which the resident requires assistance. The ISP in the record for resident #5, dated 03/09/2023, states “Resident to utilize grab bars as needed for steadiness when performing task of toileting” and describes the person who will provide services as “Self.” The ISP does not address the need for supervision.
Plan of correction
All ISP certified staff inserviced by 8/11/2023 to ensure UAI and ISP match in level of assistance needed to perform task. Administrator/Designee to perform ISP audits of 3 residents once per month for 3 months to ensure the level of assistance on UAI and ISP correlate. ISP for resident identified was corrected on 8/3/2023. [SIC]
22VAC40-73-520-I
Based on observations made during the tour of the building, the facility failed to keep current the activities schedule.
Evidence
  1. When the LI toured the safe secure unit during the inspection on 08/03/2023, the activities calendar was observed to be dated for June 2023.
Plan of correction
Activity personnel and management staff educated by 8/11/2023 on ensuring calendars reflect correct date and are updated weekly. Administrator/Designee will check once weekly for 3 months to ensure compliance. Calendar was updated and August calendar posted by 8/11/2023. [SIC]
September 19, 2022Inspection4 violations
Inspection dates
09/19/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/19/2022 Start: 9:10am-conclude 4:20pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 14 Number of staff records reviewed: 16 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 he 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 Crystal B. Mullins Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-380-A
Based on the review of resident records, the facility failed to obtain all personal and social information prior to or at the time of admission for one resident.
Evidence
  1. Resident #1 was admitted to the facility on 06/30/2022. The personal and social data sheet was blank in the following areas: Date of Birth, on page 2 the personal physician, personal dentist, local department of social services and other agency as well current behavioral and social functioning, strengths and problems.
Plan of correction
Resident social data form was completed prior to exit meeting. Administrator/designee was inserviced on 9/21/2022 in regards to completion of the personal and social information form. Administrator/designee to perform audit of social data forms at random once per month for 3 months to ensure completion of personal and social information on social data form. [sic]
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. The facility’s Medication Management Plan which was provided on the date of inspection states the following: “During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going medication persons both sign off on the accurate counts of all narcotics on the Narcotic Administration Record”.
  2. While performing an audit of the 2nd floor medication cart A at approximately 11:45 AM on the date of inspection 09/19/2022, the LI observed the narcotic count book was not completed and signed by oncoming and off-going medication staff on 9/7/2022 for the 7p – 7a shift, nor was it completed on 9/8/2022 for the 7a – 7p and 7p – 7a shifts.
Plan of correction
All medication staff inserviced by 9/30/2022 in regards to ongoing and offgoing medication persons signing on the accurate counts of all narcotics on the Narcotic Administration record. DON/designee to perform Narcotic Administration record audits at random per week for 3 months and once per month at random for 3 months to ensure accurate completion of the Narcotic Administration record. [sic]
22VAC40-73-450-C
Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include all identified needs.
Evidence
  1. The record for Resident #4 contained signed orders, dated 08/16/2022, which indicate the following: “O2 @ 2L concentrator given via nasal cannula for O2 stat less than 85% or gasping for breath, wheezing, nasal flaring, complaints of dyspnea, as needed.”
  2. The ISP for Resident #4, dated 06/02/2022, does not indicate the resident’s need for oxygen as ordered.
  3. The record for Resident #3 contained signed physician’s orders, dated 06/22/2022, which indicate the following: “OXYGEN AT 2L/MIN VIA NASAL CANULA VIA CONCENTRATOR CONTINUOUS D/T HYPOXIA RESPIRATORY FAILURE”.
  4. The ISP for Resident #3, dated 06/03/2022, states “Resident to receive oxygen from provider of choice as ordered”; however, the ISP does not specify the ordered oxygen source, the delivery device, nor the therapeutic flow rate.
Plan of correction
All ISP certified staff inserviced by 9/23/22 to include ordered oxygen source, delivery device and therapeutic flow rate for resident on ISP when there is an order for oxygen. Administrator/DON/Designee to perform ISP audit for individuals at random receiving oxygen once per month at random for 3 months to ensure source, delivery device and therapeutic flow rate are included on ISPs. [sic]
22VAC40-73-550-G
Based on record review the facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident’s record.
Evidence
  1. The record for Resident #3 contained a most recent resident rights review signed 06/03/2021.
  2. Interview with Staff #2 indicated that the 2022 review had occurred; however, it could not be located.
Plan of correction
Annual review of resident rights was located by Administrator on 9/20/2022. Administrator/Designee inserviced on 9/21/2022 in regards to annual review of resident rights. Administrator/Designee to perform resident rights audit at random once per month at random for 3 months and intermittently going forward to ensure resident rights is reviewed annually with resident. [sic]
August 8, 2022Inspection0 violations
Inspection dates
Aug. 8, 2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Crystal B. Mullins Licensing Inspector at (276) 608-1067 or by email at crystal.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 5, 2022Inspection0 violations
Inspection dates
04/05/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
The licensing inspector for English Meadows Abingdon Campus conducted the initial announced inspection on 04/05/2022. Residents in care were observed, activities were observed, lunch was observed and staff and resident interactions were observed. The building and grounds were observed and the safe secure unit was also observed. The first aid kit was checked. An exit meeting was held with the administrator and key staff on this date, 04/05/2022. No violations are being cited as a result of this inspection. If you have any questions please contact your inspector at 276-608-1067. Thank you for your assistance and cooperation.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.