VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greendale Home
18180 Rich Valley Road
Abingdon, VA 24210
(276) 628-8595

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: July 13, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 Facilities and Programs..

Comments:

A non-mandated complaint inspection was initiated on 07/13/2021 and concluded on 09/10/2021. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of the documentation required to complete the investigation. A revised copy of the violation notice was sent to the facility on 04/18/2022. The evidence gathered during the inspection supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on documentation review, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. EVIDENCE: 1. According to home health nursing notes dated 01/09/2021 a new sacral wound with excoriation and a peri wound found on resident # 1. 2. According to home health assessment history notes dated 01/11/2021 wound care was performed and the sacral ulcer was determined to be a stage II pressure ulcer. 3. Staff # 1 reported she was unaware of a stage II ulcer.
Plan of Correction:	The facility will report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. Home Health agency will report to DON and/or administrator findings of wound, an incident report will be filed with regional licensing office within 24 hours. Home Health Communication Form dated 01-11- 2021 left with facility only documents "new wound care" no new orders were documented by Home Health agency, no reports were given to DON or Administrator. Revised communication forms are now used to reflect new orders and to whom they were reported to. [sic]
Standard #:	22VAC40-73-310-A
Complaint related:	No
Description:	Based on documentation review, the facility retained a resident that they did not provide appropriate care for. EVIDENCE: 1. According to home health nursing notes services began with resident # 1 on 09/29/2020 due to resident being admitted to the hospital for a Urinary tract infection (UTI), Pyelonephritis (kidney infection) with right sided Hydronephrosis (urinary tract obstruction) and now requires a Foley catheter. According to Home Health certification and plan of care he had multiple admissions within the past few months related to urinary issues and secondary to UTI. He is at high risk for re-hospitalizations and emergent care due to recurrent UTI issues and patient requiring a Foley catheter. Home Health was ordered to assess medication compliance, recurrent UTI/Pyelonephritis and instructed on infection control measures. 2. According to home health nursing notes dated 10/01/2020 it was noted there seems to be an issue with compliance with Foley care and home health instructed both the resident and caregivers on performing care twice daily. 3. According to home health nursing notes dated 10/29/2020 resident # 1 was diagnosed with a UTI and home health administered an intermuscular injection of Rocephin and provided UTI teaching. Home health was required to visit daily for five days to administer the injection. Resident # 1 was also found to have a split of the meatus measuring 0.5 cm. 4. According to home health nursing notes dated 12/31/2020 resident # 1 was diagnosed with a UTI and home health was ordered to administer 1 gram of Rocephin intramuscularly. On this date it was noted resident # 1 was cleaned due to having a bowel movement all over him and his Foley catheter. Home health instructed on Foley care and the importance of keeping clean. Resident # 1 reported he cannot feel when he has bowel movement. Home health instructed caregivers on proper peri care and Foley care to prevent UTI's from reoccurring. 5. According to home health nursing notes dated 01/04/2021 resident # 1 had thick dark brown urine noted in resident's catheter bag and he was unable to recall when Foley was last emptied. When asked ALF staff was unable to report urine output measurements. 6. According to home health nursing notes dated 01/09/2021 a new sacral wound with excoriation and peri wound was found on resident # 1 and wound care was performed. Home health received wound care orders on this date and patient and caregivers were educated on infection prevention and pressure ulcer prevention. 7. According to home home health nursing notes dated 1/11/21, resident # 1 was reporting severe left flank pain with dark urine in color and thick with odor and was screaming out in pain with movement during skilled nursing visit. The resident's primary care physician was contacted and he was sent out to the emergency room. According to home health assessment history notes dated 01/11/2021 wound care performed on resident # 1's stage II sacral pressure ulcer. 8. According to home health nursing notes dated 01/12/2021 it was noted resident # 1 was found to be incontinent of his bowels and his Foley bag was dragging the ground due to misplacement in his wheelchair. Home Health assisted caregivers with cleaning resident and wound care was completed. 9. According to home health nursing notes dated 01/13/2021 resident #1 was noted to be cognitively impaired today. He tried to eat a napkin with lunch and was wheeling himself up and down the hallway repeatedly. The resident was unable to be reoriented and the caregivers were contacted. Resident # 1 was sent out to the Emergency Room.
Plan of Correction:	(1) Home Health Communication Form left at facility by Home Nursing Service dated 9-29-20 does not list any instructions for caregivers on infection control and does not list new information given and to whom given to. DON nor Administrator was notified of concerns. (2) Home Health Communication Form left at facility by Home Nursing Service dated 10-01-20 staff listed as person reported to does not recall order to perform foley care twice a day verbally given to her, order was not documented on communication form. Charge staff nor Administrator was notified of new order. (3) Home Health Communication Form left at facility by Home Nursing Service dated 10-29-20 reflects no documentation of the split of the urethral meatus, not reported to staff or MD and no new orders were documented on form. (4) There was no Home Health Communication Form left at facility by Home Nursing Service dated 12-31-20, DON nor Administrator was not notified of concerns, no documentation was left at facility noting caregivers' teaching/instructions. (5) Home Health Communication Form left at facility by Home Nursing Service dated 01-04-21 documents of MD notified of thick dark brown urine. Resident emptied his catheter bag himself therefore no record of intake/output was kept. (6) Home Health Communication Form left a facility by Home Nursing Service dated 01-09-21 only documents New Wound Care, new orders were not documented, documentation of patient, caregivers teaching of infection prevention and pressure ulcer prevention. DON nor Administrator was notified of concerns or instructions. (7) No Home Health Communication Form left a facility by Home Nursing Service dated 01-11-21, resident did not go to ER on this date. DON nor Administrator was notified of concerns of resident's severe left flank pain or the staging of pressure ulcer. (8) No Home Health Communication Form left a facility by Home Nursing Service dated 01-12-21, DON and Administrator was unaware that Home Health had to clean resident. (9) No Home Health Communication Form left a facility by Home Nursing Service dated 01-13-21, resident admitted to hospital on 1-13-21, hospital notes states Erythema noted around the external meatus and onto the scrotum, pressure sore at the tip of the penis. No staging of pressure ulcer was noted. The Home Health Communication Form has been revised to indicate whom the teaching was given to; to list the staff person reported to; and noted that reports are to be given to DON. All Home Health Agency's have been made aware of these revised forms and instructed to use them. Facility has also requested Home Health Agencies to document in resident chart under Nurses Notes all significant notes for residents, and to report all concerns to Administrator. [sic]
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on documentation review including the Uniform Assessment Instrument (UAI), the facility failed to complete an annual reassessment. EVIDENCE: 1. The most recent UAI for resident # 1 emailed to the licensing inspector on July 26, 2021 was dated June 30, 2020 which is past the annual reassessment date.
Plan of Correction:	Annual reassessment and assessment due to a significant change in the resident's condition, using the UAI, shall be utilized to determine whether a resident need can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. DON or administrator will monitor changes in residents' health, addressing changes on ISP, compare findings with outside Home Health agency. DON and administrator will assess all residents monthly to assure facility continues to meet resident's needs. Resident was due for a reassessment for UAI on 6-30- 21 and an Email was sent to HCS on 6-28-21 to remind assessors of due date. Facility will continue to notify assessor of UAI due date. [sic]
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on documentation review of the Individual Service Plan (ISP), the facility failed to ensure the ISP shall be reviewed at least every 12 months and as needed as the condition of the resident changes. EVIDENCE: 1. The ISP for resident # 1 dated 6/30/2020 states Home Health will perform skilled needs, frequency and duration as ordered by the Primary Care Physician. 2. According to home health nursing notes dated from 09/2020-07/2021 the duty of the home health nurse and aides is to change resident #1's Foley Catheter monthly and as needed and complete skin assessments as needed. The specific identified need of home health changing the Foley catheter and completing skin assessments were not addressed on resident # 1's ISP. 3. According to home health nursing notes dated 03/17/2021 resident #1 is at high risk of recurrent UTI's due to Foley catheter with Latrogenic Hypospadias (injury to the urethra) as a result of Foley with patient having bowel movements/incontinence on himself daily without knowing. This nursing notes states the physician is aware of the issue and risk. 4. The Uniform Assessment Instrument (UAI) for resident # 1 dated 06/30/2020 states resident # 1 is continent of his bowels and has no ongoing nursing needs. 5. The ISP dated 06/30/2020 does not address the documented service need of bowel incontinence. 6. According to home health nursing notes dated 06/25/2021 resident # 1 had what appeared to be a bug bite on his right forearm. Resident # 1 reported it was itching and he had been scratching it. The area was noted to have a small scab and is slightly edematous and hard to the touch. 7. According to physician notes dated 06/30/2021 resident # 1 was seen by the facility's nurse practitioner regarding what was identified as a spider bite on the resident's right forearm. An order was written for Clindamycin 450 mg TID for 10 days and home health to address wound and evaluate for appropriate wound care. 8. According to home health nursing notes orders were received for wound care to vigorously irrigate the wound bed with sodium chloride to wash away necrotic debris, pat dry, apply aquacel to wound bed, cover with 4x4 dressing, secure with coban and is performed every 2-3 days. 9. The most recent ISP dated 06/30/2020 does not address the documented service need for wound care. 10. The most recent ISP for resident #1 was emailed to the licensing inspector on July 19, 2021. This ISP was dated 06/30/2020 which exceeds at least the 12 month reassessment date.
Plan of Correction:	The ISP shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. All skilled needs performed by a Home Nursing Service will be addressed in detail on the ISP. Resident was prescribed and taking medication for constipation which would cause loose stool, assessor was unaware of this becoming an issue and the need to address on the UAI. Order for wound evaluation on 6-30-21 and treatment order was received by Home Health and not documented in residents' chart. A new Home Health Communication Form was revised to address problems of communication between agencies and facility staff. Resident was due for a reassessment for UAI on 6-30-21 and an Email was sent to HCS on 6-28-21to remind assessors of due date. Facility will continue to notify assessor of UAI due date. [sic]
Standard #:	22VAC40-73-450-H
Complaint related:	No
Description:	Based on documentation review as part of a complaint received by the licensing office, the facility failed to ensure that the care and services specified in the Individualized Service Plan (ISP) were provided to one resident in care. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 06/30/2020 states resident # 1 needs physical assistance with bathing. 2. The ISP for resident #1 dated 06/30/2020 specifies he needs assistance with bathing to include supervision, assistance or prompting for bathing twice weekly and as needed in shower room by direct care staff or home health aide. 3. According to the bath chart for resident # 1 submitted by the facility the last time he had a shower was on 07/07/2021 prior to being admitted to the hospital on 07/13/2021. 4. The ISP for resident # 1 dated 06/30/2020 specifies he is incontinent of his bladder and direct care staff will monitor for skin breakdown. There is no documentation of the frequency of monitoring of skin breakdown. 5. Based on documentation submitted by Emergency Department staff on 07/13/2021 there were concerns with the condition of resident #1 when he was admitted to the hospital on this date. It was documented by hospital staff on 07/13/2021, that upon arrival to the Emergency Department (ED) resident # 1 was covered in old feces. Resident # 1's sacrum and heels were observed to have pressure wounds and his sacrum also had wounds from feces that were not cleaned and bleeding. The ED staff cleaned off dried feces from resident?s hands and legs.
Plan of Correction:	The facility will ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with the ADLs and IADLs, including ambulation, hygiene and grooming including shampooing, combing/brushing hair, shaving, trimming fingernails and toenails. Bathing charts have been revised and direct care have been trained on utilizing bath chart to include when a scheduled shower in not given the resident will receive a bed bath, the chart also reflects when the scheduled shower is given on a different date or different shift. Direct Care Staff will report to charge staff and DON when a shower is not given, and they will document the reason and what will be done to correct it. Bath charts are reviewed monthly by the DON and any problems will be addressed. [sic]
Standard #:	22VAC40-73-450-H
Complaint related:	No
Description:	Based on documentation review as part of a complaint received by the licensing office, the facility failed to ensure that the care and services specified in the Individualized Service Plan (ISP) were provided to one resident in care. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 06/30/2020 states resident # 1 needs physical assistance with bathing. 2. The ISP for resident #1 dated 06/30/2020 specifies he needs assistance with bathing to include supervision, assistance or prompting for bathing twice weekly and as needed in shower room by direct care staff or home health aide. 3. According to the bath chart for resident # 1 submitted by the facility the last time he had a shower was on 07/07/2021 prior to being admitted to the hospital on 07/13/2021. 4. The ISP for resident # 1 dated 06/30/2020 specifies he is incontinent of his bladder and direct care staff will monitor for skin breakdown. There is no documentation of the frequency of monitoring of skin breakdown. 5. Based on documentation submitted by Emergency Department staff on 07/13/2021 there were concerns with the condition of resident #1 when he was admitted to the hospital on this date. It was documented by hospital staff on 07/13/2021, that upon arrival to the Emergency Department (ED) resident # 1 was covered in old feces. Resident # 1's sacrum and heels were observed to have pressure wounds and his sacrum also had wounds from feces that were not cleaned and bleeding. The ED staff cleaned off dried feces from resident?s hands and legs.
Plan of Correction:	The facility will ensure that the care and services specified in the ISP are provided to each resident. DON will be notified by staff when services are refused by resident and will be addressed with resident at that time. Direct Care and Charge staff will observe resident for cleanliness prior to resident leaving facility. [sic]
Standard #:	22VAC40-73-460-B
Complaint related:	No
Description:	Based on documentation review and an interview with staff, the facility failed to provide a prompt response to residents specific needs as reasonable to the circumstances. EVIDENCE: 1. According to a written statement submitted by staff # 1 to the LI on 08/29/2021, the resident never had an appointment with the urologist. According to home health nursing notes it was noted on three different occasions 03/26, 06/11, & 06/25 the facility would make an appointment with the urologist. Staff # 1 stated when facility staff tried to make an appointment back in March no one was taking new patients due to COVID and the appointments that were to be made in June were not. 2. According to home health notes dated 06/25/2021 the facility staff and nurse practitioner were coordinating a urology appointment. 3. According to home health nursing notes and assessment history dated 07/09/2021 wound care was provided to resident # 1 for a spider bite on his right forearm. It was noted by home health that wound continues to deteriorate, the nurse practitioner was notified and ordered a wound care consult. It was noted staff # 2 was notified and she reported she would call on 07/09/2021 and make the wound care appointment. 4. According to a written statement from staff # 1 submitted to the LI on 08/29/2021 staff # 2 called the wound care clinic and they needed a referral from the primary care physician. Staff # 2 was going to wait until 07/14/2021, which was resident # 1's next scheduled visit with the nurse practitioner; to get the referral so the appointment was not made on 07/09/2021.
Plan of Correction:	Care provision and service delivery shall be resident centered to the maximum extent possible and include resident participation in decisions regarding the care and services provided to him; personalization of care and services tailored to the resident's circumstances and preferences; and prompt response by staff to resident needs as reasonable to the circumstances. Referrals and documentation of referrals will be made in a timely manner. (1) DON tried several times to schedule urologist appointments, due to COVID new patient appointment could not be scheduled. DON tried to schedule resident with Dr Bauer (urologist), as resident had seen him before, but was informed that due to resident having a foley catheter continuously that he did not qualify for their services. (2) Home Health Nurse and nurse practitioner had also unsuccessfully tried to schedule appointments for referrals. (3) Home Health Communication Form left at facility by Home Nursing Service dated 07-09-21 does not give detail of wound, no measurements or appearance noted on form. DON notified wound care clinic at BRMC to schedule consult appointment, was instructed to get a referral from PCP, this was on Friday resident was scheduled to see NP on the following Wednesday but was admitted to hospital on Tuesday before appointment. [sic]
Standard #:	22VAC40-73-460-D
Complaint related:	No
Description:	Based on documentation review and an interview with staff, the facility failed to provide supervision of resident care including attention to the specialized needs of one resident in care. EVIDENCE: 1. Based on documentation submitted by a local hospital Emergency Department staff on 07/13/2021 there were concerns with the condition of resident #1 when he presented to the hospital on this date. It was documented by hospital staff on 07/13/2021 that upon arrival to the Emergency Department (ED) resident # 1 was covered in old feces. He had a Foley catheter in place that was covered in feces and placed in a trash bag. Resident # 1's sacrum and heels were observed to have pressure sores and his sacrum also had sores from feces. The ED staff changed resident # 1 and replaced his Foley catheter and dried feces was cleaned off resident's hands and legs. 2. According to history and physical notes from the hospital, a wound care consult was ordered for a pressure injury that was present at admission to the hospital on 07/13/2021. It was noted on 7/14/21 on the wound care consult note the areas of concern noted is the gluteal cleft related to moisture vs. pressure. 3. The individual Service Plan (ISP) from the facility for resident # 1 dated 06/30/2020 stated he was continent of his bowels. 4. According to home health nursing notes dated 06/25/2021 resident #1 is incontinent of his bowels, therefore patient is sitting with stool on his Foley catheter daily until facility staff performs incontinent care putting resident # 1 at high risk for UTI's and skin breakdown as well as his ongoing non-compliance with Foley care and securement devices. According to a verbal interview with staff # 1 she stated ,I was not aware resident # 1 had any pressure wounds or skin sores. 5. According to the hospital history and physical records dated 07/13/2021 resident # 1 was admitted to the hospital in the intensive care unit on this date with a diagnosis of septic shock. He continued to decline and developed worsening respiratory failure and he subsequently passed away on 07/20/2021.
Plan of Correction:	The facility will provide supervision of resident schedules, care, and activities, including attention to specialized needs. Staff and outside agencies will notify DON of changes in resident needs, these will be addressed on residents ISP and will be monitored for level of care to assure residents needs can be met at facility. [sic]
Standard #:	22VAC40-73-460-H
Complaint related:	No
Description:	Based on documentation review, the facility failed to ensure personal assistance and care were provided so the needs of the resident were met including bathing at least twice a week. EVIDENCE: 1. According to documented bathing charts for resident # 1 the week of May1-7, the resident did not shower on 05/04/2021 due to thunderstorms. He only showered once that week on 05/07/2021. 2. The week of June 1-8, resident # 1 only showered one time on 06/01/2021. He refused to shower on 06/04/2021 and did not shower again until 06/11/2021. 3. Resident # 1 had a shower on 06/18/2021. He refused to shower on 06/22/2021 due to thunderstorms and did not shower again until 06/25/2021 which is one shower within a week. 4. The week of 06/28/2021-07/02/2021, the resident took a shower on 06/28/2021 and refused on 07/02/2021. He did not shower again until 07/06/2021.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2-1808-A-11
Complaint related:	No
Description:	Based on documentation review and an interview with collateral, the facility failed to treat one resident in care with courtesy, respect and consideration as a person of worth, sensitivity, and dignity. EVIDENCE: 1. According to documentation submitted to the licensing office by hospital staff upon arrival to the Emergency Department on 07/13/2021 resident # 1 had a Foley catheter in place that was covered in feces and placed in a trash bag. 2. According to an interview with collateral # 1, she confirmed the facility kept resident #1's catheter wrapped in a trash bag to keep him from running over it with his wheelchair. 3. According to a written statement submitted by staff # 1, she reported resident # 1's catheter had a tendency to leak and was commonly placed in a plastic bag to prevent the leaking of urine, sometimes due to the clip on the draining tube not being closed or broken. The resident would run over the bag with his wheelchair causing the bag to leak and insurance will only pay for one catheter bag per month. The trash bag was tied and hung on the back of the wheelchair between the wheels.
Plan of Correction:	All residents will be treated with courtesy, respect and consideration as a person of worth, sensitivity and dignity. Team members will calibrate a plan to ensure each resident is encouraged to function at his highest mental, emotional, physical and social potential and at all times treated with respect, dignity and encourage self-worth. DON and Administrator will stress this with team members during monthly staff meetings, will encourage staff to report all concerns of residents not being treated with respect or dignity. Activity Director will encourage residents to express their concerns of themselves or others that are not treated with respect or dignity during the monthly resident council meetings. Activity Director will report to Administrator all concerns who will follow-up on them. [sic]