VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greystone Manor
302 Greystone Drive
Castlewood, VA 24224
(276) 762-7929

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Sept. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Two licensing inspectors conducted an unannounced license renewal inspection at Greystone Manor on 09/27/2019. The inspection began at 10:15 am and concluded at 12:45 pm. A tour of the building and grounds was conducted. Residents and collaterals were interviewed. Residents and staff interactions were observed. The noon meal and noon medication pass were observed. Resident and staff files were reviewed. Medications and Medication Administration Records were observed. The facility is licensed to provide care to 34 residents, and 27 were found to be in care at the time of this inspection. Required postings and the previous inspection were observed to be in place. An exit meeting was conducted with the administrator on 09/27/2019 and at that time the opportunity was given to find items that were not readily available in the records. As a result of this inspection, six violations are being cited. A corrective action plan should be developed addressing steps to correct the noncompliance of each standard, measures to prevent to re-occurrence, and person(s) responsible for implementing each step and/or monitoring and prevention measures. The "description of action to be taken" for each violation, along with the "date to be corrected" must be returned the licensing office signed and dated within 10 calendar days (10/12/2019) of receipt. If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based upon review of resident records, the facility failed to have all areas of the physical examination filled out by an independent physician within 30 days preceding a resident' s admission into an assisted living facility on two residents out of the sample of six. EVIDENCE: 1. Resident #2 was admitted to the facility on 10/19/2018. His physical did not address the question of whether or not he was able to self administer his medications. 2. Resident #3 was admitted to the facility on 08/02/2019 and his admission physical was dated 07/17/2019. His physical did not address the question of whether or not he was able to self administer his medications.
Plan of Correction:	In the future all physicals will be checked for all necessary information. [sic]
Standard #:	22VAC40-73-320-B
Description:	Based upon review of resident records, the facility failed to obtain annual tuberculosis risk assessments on three residents out of the sample of six. EVIDENCE: 1. Resident # 5 was admitted to the facility on 10/12/2005. He has the required initial tuberculosis risk assessment, but was missing a subsequent tuberculosis evaluation for the following years: 2006, 2008, 2009, 2010, 2011, 2012, and 2013. 2. Resident # 6 was admitted to the facility on 07/18/2005. He has the required initial tuberculosis risk assessment, but was missing a subsequent tuberculosis evaluation for the following years: 2005, 2006, 2008, 2009, 2010, 2011, and 2012. 3. Resident # 4 was admitted to the facility on 06/04/2003. He had the required initial tuberculosis risk assessment, but was missing a subsequent tuberculosis evaluation for the following years: 2003, 2004, 2005, 2006, 2007, and 2008.
Plan of Correction:	In the future, TB evals and other primary information will not be removed from the main resident folder to avoid misplacing these items. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on observations made during review of resident records, the facility failed to ensure that at the time of admission to an assisted living facility or prior to admission, all information on the personal and social information on a person shall be obtained. EVIDENCE. 1. Resident # 3 was admitted tot he facility on 08/02/2019. On Resident #3's personal and social information form, the "current behavioral and social functioning" was left blank.
Plan of Correction:	In the future, all documentation will be completed upon admission. [sic]
Standard #:	22VAC40-73-550-G
Description:	Based on review of resident records, the facility has failed to review the rights and responsibilities of residents in assisted living facilities annually with each resident or his legal guardian. EVIDENCE: 1. Resident # 6 was admitted to the facility on 07/18/2005. Resident rights and responsibilities were not reviewed for the following years: 2006, 2007, and 2008. 2. Resident # 5 was admitted to the facility on 10/12/2005. Resident rights and responsibilities were not reviewed for the following years: 2006, 2007, 2008, and 2009. 3. Resident # 4 was admitted to the facility on 06/04/2003. Resident rights and responsibilities were not reviewed for the following years: 2003, 2004, 2005, 2006, 2007, and 2008.
Plan of Correction:	In the future, all primary documents will be kept in the resident's main file to avoid misplacing them. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure that the building was free from foul, stale and musty odors. EVIDENCE: 1. Resident Room # 12 had a noticeably strong, foul odor of stale urine. 2 According to staff this resident does wear pull-ups and can change those herself; however, she has to be prompted to do so.
Plan of Correction:	In the future, we will continue to make hourly rounds and encourage her to change regularly [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on the morning tour of the building, the facility failed to ensure that all toilets were kept clean and in god repair. EVIDENCE: 1. The toilet in the downstairs women's bathroom was observed to be stained and unclean.
Plan of Correction:	Bathrooms are checked every 2 hours to ensure cleanliness. We will continue checks. [sic]