VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gregory's Rest Home
29255 &29271 Walker Lane
Meadowview, VA 24361
(276) 944-5350

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Jan. 30, 2023

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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/30/2023, 11:45am ? 4:19pm 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: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Meal, activity, med pass, building Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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 on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at (276) 608-3514r or by email at rebecca.berry@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on staff interviews and observations made during the medication cart audit, the facility failed to have a method defined in their medication management plan to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. During the medication cart audits the LI requested to see how the facility maintains documentation of all controlled substances during medication administration shift changes. 2. According to Staff #4 in House #2 and Staff #1 in House #1 the facility does not document the count of controlled substances when medication administration shift changes.
Plan of Correction:	Facility developed a form and policy to implement a requirement of a written staff audit of the controlled Substance medication count located at the facility during each Medication Aid?s shift change. [SIC]
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records, the facility failed to ensure the record contains the physician?s or other prescriber?s signed written order or a dated notation of the physician?s or other prescriber?s oral order, and to organize orders chronologically in the record for one of the five resident records reviewed. EVIDENCE: 1. The Medication Administration Record (MAR) for resident #4, dated 01/01/2023 to 01/31/2023 indicates the resident is receiving Meclizine 25 mg tablet, 1 tablet by mouth 3 times a day for vertigo. 2. The order found in the record for resident #4, signed November 28, 2022, indicates the resident is prescribed Meclizine 12.5mg tablet, take 1 tablet by mouth three times a day for vertigo. 3. The documentation for an oral order for Meclizine 25 mg tablet, 1 tablet by mouth 3 times a day for vertigo, for resident #4 was found in House #2 by staff #4. However, it was not in the record for resident #4, which was located in House #1 at the time of inspection.
Plan of Correction:	All resident documentation will be filed in the correct order under the correct tab within 1 week of the resident seeing a physician or therapist. [SIC]