VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greenfield Reflections of Woodstock
1222 S. Ox Road
Woodstock, VA 22664
(540) 459-2200

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: March 25, 2022

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

1. Request an additional pharmacy review to assist in process of updating MARs. 2. Review your fire drill times and work toward more variation - keep in mind these should be done with staff available at the time a fire may occur. 3. Review stoma care with all staff - reviewing for them the things which only a nurse can do.

Comments:

An unannounced monitoring inspection was conducted for this stand alone memory care facility. One violation in the area of medication documentation was found. details can be found in the violation portion of this report. This violation was a result of the medication administration records reviewed. Three staff files and four resident files were reviewed. The files were in order and in compliance with the required documentation outlined in the standards. Outside inspections were current as were related fire and emergency drills. Postings were as required. The facility was secure as required for the program type. The overall building was clean and odor free. Residents were participating in activities as per the posted schedule. Thank you to residents, families and staff for your cooperation during this monitoring inspection process. Should you have questions or concerns please call (540) 292-5930 or email this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based on a review of medication administration records (MARs) there was inconsistent documentation regarding follow up with a physician when a medication was not effective to determine the next course of action. The parameters of when to hold medication or contact a physician were also inconsistent.
Plan of Correction:	The ED who is a nurse or designee will provide an in-service to all registered medication aides as it pertains to medication administration documentation in the electronic MAR system. The ED will contact the pharmacy regarding additional modifications to the electronic MAR system to support complete and accurate documentation. The ED and or designee will review the MARS every week for four weeks and then quarterly going forward to ensure maintenance of compliance.