VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gray Ridge Village LLC
155 Ridgefield Rd
Marion, VA 24354
(276) 521-0784

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Dec. 8, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 12/08/2022 Begin: 11:0am End: 5:26pm 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: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: 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 For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B.Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-290-B
Description:	Based on observations made during the tour of the physical plant, the facility failed to post the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. EVIDENCE: 1. The white dry erase board in the hallway outside the administrator?s office indicating the on-site person in charge had not been updated since 11/24/2022. The administrator explained this information was now posted on a bulletin board in the activity room. The information was available on the bulletin board as stated but was not in a location clearly visible to the public
Plan of Correction:	White Board, at the entrance, will be update by the RMA working on Sunday of each week. The weekly schedule will be posted under the white board showing list of staff working by 12-11-22 Med techs will perform, and RCD and Administrator will monitor. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to have a physical examination by an independent physician completed within 30 days prior to admission to an assisted living facility and the exam shall contain required items. EVIDENCE: 1. Resident #8 has a physical completed on 05/20/2022. Allergies were identified but, there were no reactions documented. 2. Resident #9 has a physical completed on 05/18/2022. Allergies were identified but, there were no reactions documented. 3. These two pieces of evidence were cited at the previous inspection (06/16/2022).
Plan of Correction:	Allergies will be listed on those physicals the next time the nurse practitioner does rounds at this facility. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, the facility failed to adhere to their medication management plan for proper disposal of medication. EVIDENCE: 1. Resident #1 is prescribed Insulin Aspart Flexpen 100 Unit/ml Pen, inject 6 units SQ three times a day before meals for DM (hold for BS <80), GEN: Novolog Flexpen U-100 insulin. There was an open date of 11/07/2022 on the packaging, and the medication had not been disposed of at time of inspection on 12/08/2022. Per manufacturer and FDA information, storage conditions indicate the medication must be disposed of after 28 days.
Plan of Correction:	All medication will be checked on Fridays to make sure no medications are older than 28 days from open date beginning 1-20-23. RCD will perform and Administrator will monitor. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the noon medication pass and the medication cart audit, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident #5 is prescribed Mometasone Furoate Nasal Spray, inhale two sprays in each nostril every day for nasal congestion. There was an open date of 10/17/2022 on the packaging. According to the directions on the label and the contents in the container of 120 metered sprays, the medication should have been depleted after 30 days of use, which would have been by 11/17/2022. At the time of inspection on 12/08/2022, the container remained approximately half full. 2. Resident #2 is prescribed Spiriva 18 MCG CP-Handihaler, inhale contents of one capsule two times once daily for COPD every day. This medication did not contain an open date but had been opened and used. 3. Resident #3 is prescribed Iprat-Albut 0.5-3(2.5) MG/3 ML, inhale contents of one vial via nebulizer every six hours as needed for wheezing. This medication did not contain an open date but had been opened and used. 4. Resident #4 is prescribed Symbicort 160/4.5 MCG INHAL, inhale two puffs into lungs two times a day for COPD. This medication did not contain an open date but had been opened and used. 5. Resident #6 is prescribed sucralfate 1 GM tablet, take one tablet by mouth before meals and at bedtime for gastritis. The licensing inspector observed the medication was administered with yogurt, however the inspector was unable to locate a physician?s order providing instructions that the medication is to be taken with food.
Plan of Correction:	All RMAs will be trained in the importance of having an open date on inhalers, liquids, powers, creams, insulin and other such medications. They will be instructed that medication is only good for 28 days from open date. Any RMA found to not be complying with performing as instructed will be given a write up and further education given 1-27-23. RMAs will be instructed that medication cannot be placed in food unless they have a physician?s order to do so. By 1-27-23. RMAs will also be instructed on giving medications as ordered and if they are refusing as ordered physician will be notified by 1-27-23. RMAs will also be instructed to sign MARs as they go as to not miss medications on the MARs. RCD will also monitor weekly MARs to ensure all staff are signing medications they are giving 1-27-23. RCD and Administrator will monitor. [sic]
Standard #:	22VAC40-73-680-H
Description:	Based on a review of resident medication administration records (MARs), the facility failed to document all medications administered to residents, including over-the-counter medications and dietary supplements. EVIDENCE: 1. The MAR dated 11/11/2022-12/10/2022 for resident #6 does not have staff initials for the administering of Sucralfate 1 GM tablet 3PM dose, and 3 salt packets with supper, on 11/28/2022, and Permetherine Cream 5% at bedtime, on 12/07/2022. 2. The MAR dated 11/11/2022-12/10/2022 for resident #7 does not have staff initials for the administering of Tizanidine HCL 2 MG tablet 6AM dose on 11/27/2022 and Acetaminophen 325 MG 3PM dose, Hydrocodone-Acetaminophen 5-325 MG 2PM dose, and Tizanidine HCL 2 MG tablet 3PM dose, on 11/20/2022. Additionally, there are no staff initials for the administering of Vitamin B-12 1000 MCG tablet on 12/01/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/06/2022, 12/07/2022 and 12/08/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-C
Description:	Based on observations made during the tour of the physical plant, the facility failed to ensure bedrooms contain a sturdy chair for each resident. EVIDENCE: 1. In resident room number 37, no sturdy chairs were found. The room appeared to accommodate two residents. 2. Resident room numbers 1, 5, 10, and 26 had two residents in each room, and only one chair.
Plan of Correction:	All residents was provided with chairs in their rooms. Residents have been carrying the chairs out to the porches to sit in. Residents will all have chairs placed back in their rooms by Direct Care Staff by 1-27-23. Residents will also be instructed that the chairs must stay in their rooms in resident Lead Direct Care Staff, RCD and Administrator will monitor [sic]
Standard #:	22VAC40-73-860-B
Description:	Based on observtiions made during the tour of the building, the facility failed to make sure that all buildings were ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. Room #5 was observed to have a foul odor. 2. Room #17 and #26 was observed to have a strong urine odor.
Plan of Correction:	All staff in the facility will be aware of foul odors in the facility and will alert the proper staff so action can be taken to prevent/eliminate the odor. [sic]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the physical plant, the facility failed to ensure hot water at taps available to residents is maintained within a temperature range of 105-120 degrees Fahrenheit. EVIDENCE: 1. In resident room number 10, the hot water at the bathroom sink reached a temperature of 137.3 degrees Fahrenheit.
Plan of Correction:	Water temperatures are to be checked by maintenance staff monthly, written log kept and if range is out of the 105-120 degrees to be immediately adjusted and rechecked by 01-27-23. Maintenance, Administrator will monitor. [sic}]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the physical plant, the facility failed to ensure the exterior of all buildings are maintained in good repair. EVIDENCE: 1. A hole was found in the outer pane of glass in a window to the left of the exterior door in the tv room. Shards of glass were found on the brick window ledge below.
Plan of Correction:	ighlands glass company has been called regarding broken window. They will be out to assess and fix if possible, by 2/3/23. Should they not be able to repair on site and must order, GRV will obtain a written statement for their plan of correction to broken glass and time frame it will take to complete. I do want to note that this is a double pane window and the inside glass to the facility is not broken. Maintenance and Administrator to monitor. [sic]
Standard #:	22VAC40-73-880-B
Description:	Based on observations made during the tour of the physical plant, the facility failed to ensure a space heater was used only to provide or supplement heat in the event of a power failure or similar emergency and had been approved by the appropriate fire official. EVIDENCE: 1. In room number 2, a portable heating unit was found to be in operation at the time of inspection. There was not a power failure or similar emergency at the time of inspection.
Plan of Correction:	Office for Room #2 has removed heater and will only use in an emergency of power failure. Removed on 12/9/22. [sic]
Standard #:	22VAC40-73-920-C
Description:	Based on observations made during the tour of the physical plant, the facility failed to ensure ventilation to the outside in order to eliminate foul odors in all bathrooms. EVIDENCE: 1. In resident room number 36, the bathroom exhaust fan did not appear to be in working order as it made no sound when switched on.
Plan of Correction:	Room #36 will have exhaust fan repaired by 02/03/23. Room #17 and Room #26 both have residents who are incontinent, and their mattress will be cleaned daily to help eliminate odors. Maintenance, Direct Care, RCD, RMAs and Administrator will monitor [sic]
Standard #:	22VAC40-73-960-B
Description:	Based on observations made during the tour of the physical plant, the facility failed to ensure the fire and emergency evacuation drawing shows areas of refuge and assembly areas. EVIDENCE: 1. Areas and refuge and assembly areas were not identified on the facility?s posted fire and emergency evacuation drawing.
Plan of Correction:	Facility will make sure fire drawing includes all necessary markings. [sic]