English Meadows Berryville Campus

Based on resident record review and staff interview, the facility failed to ensure the individual?s needs could be met prior to admission by reviewing information, including a documented interview between administrator, the individual, and his legal representative. Evidence: 1. Resident 2?s record did not contain a documented interview between the administrator, the individual, and his legal representative. 2. During an interview with the LI on 9/17/2025, staff 1 confirmed the required interview was not conducted and documented between the administrator, resident 2 and legal representative.

Based on resident record review, the facility failed to ensure a mental health screening was conducted prior to admission if behaviors occurred within the previous six months that were indicative of behavioral disorders and caused concern for the health, safety, or welfare either of the individual or others who could be placed at risk of harm by that individual. Evidence: 1. The Mental Health Screening Determination Form for resident 2 was dated 3/13/2025, day of admission. Question 2 on the form asked, ?If a mental health screening was recommended but there will be a delay in having it completed, and the results made available to the facility, explain the reason for the delay and the expected length of the delay?, was marked N/A. The physician for resident 2 recommended a psychological evaluation on 2/7/2025. Form was marked ?yes? that resident 2?s psychosocial and behavioral history required special considerations for the facility to help meet the resident?s mental health needs with only ?memory care? listed as the consideration. 2. Resident 2 was not seen by a qualified mental health professional until 3/27/2025. Resident 2 had documented aggressive altercations with other residents on four separate occasions prior to the 3/27/2025 appointment. 3. During an interview with the LI on 9/17/2025, staff 1 confirmed that documentation did not exist to reflect a mental health screening was conducted prior to admission.

Based on resident record review and staff interview, the facility failed to determine appropriateness of admission, for an individual with behavioral disorders, by obtaining information about the individual's psychosocial and behavioral functioning from primary sources, such as family members, friends, or physician. The facility must document the source and content of the information obtained. Evidence: 1. Resident 2?s record did not contain documentation that the psychosocial and behavioral history or the source of the information was reviewed to determine appropriateness prior to admission. 2. During an interview with the LI on 9/17/2025, staff 1 confirmed that documentation did not exist to reflect the facility obtained information about resident 2?s psychosocial and behavioral functioning from primary sources to determine the appropriateness of the admission.

Based on resident record review and staff interview, the facility failed to use the psychosocial and behavioral history in the development of the person?s individualized service plan. Evidence: 1. Record for resident 2, admitted 3/5/2025, contained The Assessment for Serious Cognitive Impairment dated 2/7/2025. On that assessment, the physician documented under additional comments, ?gets agitated, need geriatric psych eval?. 2. The Initial Uniform Admission Instrument ( UAI

Based on record review and staff interviews the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record the date this information was ascertained. Evidence: 1. Record for resident 2, admitted 3/5/2025, did not contain evidence of a registered sex offender search. 2. During an interview with the LI on 9/17/2025, staff 1 confirmed the registered sex offender search was not completed prior to admission.

Based on record review, the facility failed to ensure an UAI

Based on record review and staff interview, the facility failed to ensure the preliminary plan of care was developed, on or within seven days prior to admission, to address the basic needs of the resident that adequately protected his health, safety, and welfare.' Evidence: 1. Record for resident 2, admitted 3/5/2025, did not contain a preliminary plan of care. The only Individualized Service Plan ( ISP

Based on record review, the facility failed to ensure Individualized service plans ( ISP

Based on resident record review, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. Record for resident 2, admitted 3/5/2025, contained The Assessment for Serious Cognitive Impairment dated 2/7/2025. On that assessment, the physician documented under additional comments, ?gets agitated, need geriatric psych eval?. Resident 2 did not have a psychiatry consultation until 3/27/2025. 2. On 3/26/2025, resident 2 choked resident 1. 3. On 3/28/2025, resident 2 pushed resident 1 to the floor. Resident 1 was sent to hospital and admitted for a broken hip needing surgical repair. 4. On 4/8/2025, resident 2 choked another resident and tried to throw him out of a window. 5. Facility Issued a letter to terminate resident 2?s agreement effective immediately on 4/10/2025, which was 28 days after aggressive behaviors towards staff and residents began. 6. Resident 2?s medications for hypertension and hyperlipidemia were delayed by 9 days upon admission. The medication to help control resident 2?s behaviors was delayed by 11 days upon admission.

Based on resident record review and staff interview, the facility failed to administer medications in accordance with the physician?s prescribed order. Evidence: 1. Resident 2, admitted 3/5/2025, had a signed physician?s order, dated 2/7/2025, listing Norvasc (amlodipine) 10mg daily for hypertension, Lipitor (atorvastatin) 10 mg daily for hypertension, and Seroquel (quetiapine) 50 mg daily for agitation/insomnia. 2. On March 2025 Medication Administration Record ( MAR

Based on observation during the facility tour and staff interview, the facility failed to ensure special environmental precautions were taken to eliminate hazards that posed a risk to the safety and well-being of the residents. Evidence: 1. During a facility tour on 09/17/2025, two licensing staff noted five electrical breaker panels located in the main hallway which were not secured/locked. 2. During an interview with licensing staff on 09/17/2025, staff 2 acknowledged the breaker panels were not locked allowing resident access which could pose a risk to the resident?s safety and well-being. 3. Photo evidence taken.

Based on resident record review and staff interview, the facility failed to ensure whether placement in the special care unit due to a serious cognitive impairment was appropriate with the decision in writing and retained in the resident?s file. Evidence: 1. Resident 5 was admitted to the facility and the secure care unit on 06/03/2025. There was no documentation in resident 5?s record to support the placement as appropriate. 2. During an interview with licensing staff on 09/17/2025, staff 2 and 3 confirmed the required documentation was not present in the resident?s record as required.

Based on record review and staff interview, the facility failed to ensure the disclosure statement was on a form developed by the department. Evidence: 1. Resident 2 (admitted 06/03/2025) and resident 4 (admitted 04/30/2025) records contained a disclosure statement prepared on the form version number 032-05-0849-06-eng (10/19) which is not the updated version of the required disclosure statement. 2. During an interview with the LI on 07/14/2025, staff 1 acknowledged that the facility was not using the most recent version of the department developed disclosure statement form.

Based on staff record review and staff interview, the facility failed to ensure that staff verified the receipt of their job description. Evidence: 1. On 07/14/2025, four of four staff records reviewed did not include job descriptions. 2. During an interview with the LI on 07/14/2025 staff 1 acknowledged that none of the staff have signed job descriptions.

Based on resident record review and staff interview, the facility failed to ensure that a fall risk rating was reviewed and updated after every fall. Evidence: 1. Resident 5 (admitted 05/24/2024) had a documented fall on 08/11/2025 in which resident was diagnosed with a closed head injury by the local hospital. 2. During an interview with licensing staff on 09/17/2025, staff 2 confirmed a fall risk rating was not completed post fall as required by the standard.

Based on resident record review and staff interview, the facility failed to show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls. Evidence: 1. Resident 5 (admitted 05/24/2024) had a documented fall on 08/11/2025 resulting in a closed head injury. 2. During an interview with licensing staff on 09/17/2025, staff 2 confirmed the facility did not conduct an analysis of the circumstances of the fall or interventions initiated to prevent subsequent falls.

Based on resident record review and staff interviews the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record the date this information was ascertained. Evidence: 1. Licensing staff reviewed records for resident 2 (admitted 06/03/2025), resident 3 admitted (07/26/2024), and resident 4 (admitted 04/30/2025) all of which did not contain documentation of a completed registered sex offender search conducted prior to admission. 2. During an interview with licensing staff on 09/17/2025, staff 2 and staff 3 confirmed the registered sex offender was not documented in the resident record as required.

Based on record review and staff interview, the facility failed to ensure that upon admission an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system was provided. Evidence: 1. Resident 4 record (admitted 04/30/2025) reviewed on 07/14/2025 did not include an acknowledgment of having received the orientation, as there was only a blank unsigned copy in the resident record. 2. During an interview with the LI on 07/14/2025, staff 3 acknowledged there was no record of orientation in the file for resident 4.

Based on resident record reviews and staff interviews, the facility failed to ensure the ISP

Based on resident record reviews and staff interviews, the facility failed to ensure that the Individualized Service Plan ( ISP

Based on observation during facility tour and staff interview, the facility failed to provide freedom of movement for residents to their personal spaces by ensuring that the facility does not lock residents out of their rooms. Evidence: 1. During a facility tour of the secure care unit on 09/17/2025, two licensing staff observed resident 2?s door locked (admitted 06/03/2025 to secure care unit). 2. Licensing staff checked other resident doors on the secure care unit and found they were locked also. 3. During an interview with licensing staff on 09/17/2025, staff 13 confirmed that all of the residents doors were locked on the secure care unit and stated, ?we lock the doors so they (residents) don?t hide from us.?. 4. During an interview with licensing staff on 09/17/2025, staff 2 acknowledged the resident doors leading to their respective bedrooms on the secure care unit should not be locked preventing entry.

Based on observation during facility tour and staff interview, the facility failed to ensure that resident records were kept in a locked area. Evidence: 1. On 07/14/2025 during a tour of the facility, the Licensing Inspector (LI) was able to open the medication room door where resident records were stored. 2. During an interview with the LI on 07/14/2025, staff 1 stated they were not aware that the electromagnetic lock was not operational. 3. Photo evidence taken.

Based on observation during facility tour and staff interview, the facility failed to ensure that all resident records were treated confidentially. Evidence: 1. On 09/17/2025 during a tour of the facility, two licensing staff observed resident files left unattended in an open exam room, resident specific information left on top of an unattended medication cart, and the laboratory services binder left unattended on top of the counter at the nurses station. 2. During an interview with licensing staff on 09/17/2025, staff 2 acknowledged the resident records and resident information were left unattended and therefore not treated confidentially as required. 3. Photo evidence taken

Based on observation during facility tour and staff interview, the facility failed to ensure menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents. Evidence: 1. During a tour of the facility on 09/17/2025, two licensing staff observed a blank menu board located in the secure care unit. 2. During an interview with licensing staff on 09/17/2025, staff 2 confirmed the menu board had not been updated and did not contain the menu for the current week as required. 3. Photo evidence taken.

Based on facility record review and staff interview, the facility failed to ensure there was an oversight at least every six months of special diets by a dietitian or nutritionist for each resident who had such a diet. Evidence: 1. On 07/14/2025, documentation reviewed for special diet oversight was limited to a report from August 2024. 2. During an interview with the LI on 07/14/2025, staff 1 acknowledged there was no additional documentation as they did not have a registered dietician available.

Based on observation during facility tour and staff interview, the facility failed to ensure that all medications prescribed for residents were kept in a storage area that was locked. Evidence: 1. During a facility tour on 09/17/2025, two licensing staff observed resident medications left unattended on the nurses station. 2. During an interview with licensing staff on 09/17/2025, staff 2 acknowledged the medications were not kept locked in the medication cart as required. 3. Photo evidence taken.

Based on resident record review and staff interview, the facility failed to ensure medication ordered for PRN

Based on medication cart audit, facility record review and staff interview, the facility failed to ensure medication ordered for PRN

Based on observation during the facility tour, facility record review and staff interview, the facility failed to ensure when oxygen was provided to a resident, a ?no smoking oxygen in use? sign was posted outside any room of the facility where oxygen was in use. Evidence: 1. Five residents were noted to have oxygen ordered. Resident 2 (admitted 06/03/2025), resident 4 (admitted 04/30/2025) and resident 8 (admitted 04/14/2025) did not have the required oxygen sign posted outside of their rooms. 2. During an interview with licensing staff on 09/17/2025, staff 2 confirmed three of the five residents with oxygen ordered did not have the required sign posted outside of their room. 3. Photo evidence taken.

Based on observation during the facility tour and staff interview, the facility failed to ensure bedrooms contained all of the required items listed within the subsection. Evidence: 1. On 09/17/2025 two licensing staff completed a tour of the secure care unit. 2. Resident 2 (admitted 06/03/2025) did not have a table accessible to the bed, operable bed lamp, or a sturdy chair. Review of resident 5?s record did not reflect a request from the resident or legal representative to not have the required items placed in the resident room. 3. Photo evidence taken

Based on facility record review and staff interview, the facility failed to provide a written response to the resident council prior to the next meeting addressing any recommendations, problems, or concerns identified by the council. Evidence: 1. On 09/17/2025 licensing staff reviewed resident council meeting minutes dated 06/21/2024,06/25/2025, 07/25/2025 and 08/26/2025. 2. Licensing staff requested the written response for the reviewed resident council meeting minutes. 3. During an interview with licensing staff on 09/17/2025, staff 3 acknowledged the facility did not provide a written response and stated the minutes had been sent to their corporate office with a request to provide a written response but one was not provided.

Based on observation during the facility tour and staff interview, the facility failed to ensure cleaning supplies and other hazardous materials were kept locked. Evidence: 1. During facility tour on 09/17/2025, two licensing staff observed an unlocked/unattended activity room with cleaning supplies left on the counter and bulk glue sitting on the floor. 2. During an interview with licensing staff on 09/17/2025, staff 2 acknowledged the activity area was open and unattended with the cleaning supplies and bulk glue left out in the open. 3. Photo evidence taken.

Based on observation during the facility tour and staff interview, the facility failed to ensure all buildings were well-ventilated and free from foul odors. Evidence: 1. During a tour of the secure care unit on 09/17/2025, two licensing staff noted strong urine smell throughout the unit. 2. During an interview with licensing staff on 09/17/2025, staff 2 acknowledged the secure care unit was not free from foul odors.

Based on facility record review and staff interview, the facility failed to ensure an annual inspection by the appropriate fire official. Evidence: 1. The documentation of the last fire marshal inspection was dated 03/14/2024. 2. During an interview with the LI on 07/14/2025, staff 1 acknowledged that the annual fire inspection for 2025 had not been scheduled.

Based on staff interview and facility record review, the facility failed to document annual contact with the local emergency coordinator. Evidence: 1. On 07/14/2025 the LI requested documentation of annual contact with the local office of emergency management. 2. During an interview with the LI on 07/14/2025, staff 1 stated they could not determine if this had been done as the maintenance director had left and there was no documentation found.

Based on facility record review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities with the review documented by signing and dating. Evidence: 1. On 07/14/2025 the LI requested verification of semi-annual reviews of the emergency preparedness and response plan with all staff and residents. 2. During an interview with the LI on 07/14/2025, staff 1 stated this had been done with the managers in April, but not with all staff or residents as required by the standard.

Based on facility record review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities with the review documented by signing and dating. Evidence: 1. On 07/14/2025 the LI requested verification of semi-annual reviews of the emergency preparedness and response plan with all staff and residents. 2. During an interview with the LI on 07/14/2025, staff 1 stated this had been done with the managers in April, but not with all staff or residents as required by the standard.

Based on facility record review and staff interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation were conducted in accordance with the current edition of the Virginia Statewide Fire Prevention Code with required drills for each shift in a quarter not conducted within the same month. Evidence: 1. Documentation of fire drills showed the facility completed fire drills on 02/28/2025 at 7:00 a.m. (first shift), 04/01/2025 with not start/stop time listed, 05/05/2025 at 7:00 a.m. (first shift), 08/04/2025 at 9:00 p.m. (second shift), 08/15/2025 at 7 a.m. (first shift) and 09/09/2025 at 1:30 p.m. (first shift). 2. During an interview with licensing staff on 09/17/2025, staff 2 confirmed the fire drills were not conducted on each shift during the quarter.

Based on facility record review and staff interview, the facility failed to ensure a record of the required fire and emergency evacuation drills were kept in the facility for two years with the record containing all the requirements listed in the subsection. Evidence: 1. On 07/14/2025 the LI requested records for fire and evacuation drills since July 2024. No documentation could be found for August 2024 through January 2025. 2. During an interview with the LI on 07/14/2025, staff 1 stated that it did not appear that monthly drills had been entered in the electronic system, and no other records could be found to provide for LI review.

Based on facility record review and staff interview, the facility failed to ensure at least once every six months, all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced with documentation of the exercise maintained at the facility for two years. Evidence: 1. On 07/14/2025 the LI requested records for resident emergencies documenting on-duty staff participation for each shift since July 2024. 2. During an interview with the LI on 07/14/2025, staff 1 stated that only an elopement drill had been practiced and there was no record for an exercise in which the procedures for resident mental health and medical emergencies were practiced by the staff on-duty.

Based on facility staff record review and staff interview, the facility failed to retain the original criminal history record report (CHRR) at the facility. Evidence: 1. During a record review conducted on 07/14/2025 and 09/17/2025 by licensing staff, evidence of completed CHRR?s was not present in any of the facility leadership staff files. 2. During an interview with licensing staff on 07/14/2025, staff 3 confirmed the CHRR?s were held offsite at the corporate office and not retained onsite in the facility staff files.

Based on document review and staff interview, the facility failed to ensure a notation was made in the resident's record of notice given to legal representative or contact person of an injury, including the date, time, caller, and person notified. Evidence: 1. A 24-hour shift report for 3/5/2025 documented a skin tear on resident 1?s right finger. 2. On 4/28/2025, staff 1 stated notes pertaining to notifications given to a legal representative would be handwritten in a notebook. Staff 1 looked through notebooks and acknowledged there was no written note indicating notice was given to resident 1?s legal representative following observation of skin tear on 3/5/2025.

Based on resident record review, document review and staff interview, the facility failed to implement the written plan for medication management. Evidence: 1. Facility reported a medication error for resident 1 to the regional licensing office on 12/15/2024. 2.On 12/15/2024, family members inquired why Gabapentin was being administered to resident 1. After checking with the pharmacy, it was determined the pharmacy had incorrectly entered an order for Gabapentin for resident 1 which was intended for a different resident at another facility. The Gabapentin was delivered to the facility and was entered on resident 1?s electronic Medication Administration Record ( MAR

Based on staff interview, the facility failed to ensure the resident record contained the physician?s signed written order. Evidence: On 1/15/2025, staff 1 acknowledged that on 12/06/2024, staff 2 seeing a pending order in system for resident 1 and having the medication on-site, approved this order without having the physician?s signed written order on hand to verify.

Based on document review, resident record review and staff interview, the facility failed to provide supervision of resident?s specialized needs to prevent wandering from the premises. Evidence: 1. On 10/30/2025 the facility submitted an incident report to the Licensing Inspector (LI) about a resident that had left the secure unit. The report stated that on 10/29/2024 at 9:01 p.m., the Clarke County Sheriff?s Office contacted the facility to inquire of any missing residents and relayed that resident 1 was at a local fast-food restaurant located approximately 0.5 miles away at the intersection of Mosby Boulevard and US 340. Dispatch had received a call at 8:49 p.m. to report a woman walking along the side of the road. 2. Temperatures on the evening of 10/29/2025 were approximately 59 degrees, winds at 7 mph and conditions were fair per historical reports from Weather Underground. 3. Resident 1 was assessed by an independent psychologist on 6/28/2024 as having serious cognitive impairment and unable to recognize danger or protect her own safety and welfare. Resident 1 was admitted to the facilities safe, secure environment on 7/3/2024. 4. During an interview with the LI on 1/15/2025, staff 1 stated that resident 1 was observed in the common area at 8:20 p.m. with staff present. At 8:23 p.m. resident 1 was observed following staff 2 exiting the safe, secure environment from a locked door to a staff hallway which led to the parking lot. Resident 1 was returned to the facility by sheriff?s office at 9:34 p.m.