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: Jan. 31, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 01/31/2023; 10:15am ? 5:21pm 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: 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 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on staff interview and observations made during the tour of the building, the facility failed to have a listing of all staff with current certification in first aid or Cardiopulmonary Resuscitation (CPR) posted in the facility and readily available to all staff. EVIDENCE: 1. The LI could not locate the list of staff certified in first aid and CPR listed posted in the facility during the 01/31/2023 inspection. 2. According to staff #6, a current list of staff certified in first aid and CPR is not posted in the building at this time.
Plan of Correction:	CPR and First Aid list will be posted in the medication room. Administrator to monitor [SIC]
Standard #:	22VAC40-73-310-B
Description:	Based on a review of resident records, the facility failed to maintain verification of a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual resident and his or her legal representative, if any, for one of the nine resident records reviewed. EVIDENCE: 1. Resident #5 was admitted to the facility on 01/20/2021 and there was no verification/acknowledgement of the required interview found in the record.
Plan of Correction:	There was a previous administrator when this resident was admitted. Documented interview was completed on 2-1-23 for Resident #5 and all other admissions will have documented interview completed before admission. Admissions, Administrator to monitor [SIC]
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the protentional resident will have a length of stay greater than three days, for one of the nine resident records reviewed. EVIDENCE: 1. Resident #5 was admitted to the facility on 01/20/2021 and there was no documentation found in the record indicating the facility ascertained whether the resident is a registered sex offender. The sex offender screening for resident #5 was obtained by staff #6 during the onsite inspection.
Plan of Correction:	Again there was a previous administrator when this resident was admitted. Sex offender check was done while inspector was on site. All prior admissions have had sex offender checks prior to admission to the facility and going forward will continue to have all sex offender checks done prior to admission. Admissions, RCD to monitor [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on Individualized Service Plans (ISPs) for three of the nine resident files that were reviewed; additionally, the facility failed to provide a reasonable time frame to achieve the expected outcome for four of the nine resident files that were reviewed. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) in the record for resident # 1, dated 12/02/2022, identifies short-term memory loss, long-term memory loss and judgement problems with regard to cognitive function. The ISP dated 12/22/2022 in the record for resident # 1 does not address these needs. Regarding the additional needs addressed on the ISP for resident # 1, the date the needs were identified is identical to the date of time frame for expected outcome: 12/22/2022. 2. The ISP in the record for resident #4, dated 01/20/2023, uses identical dates for the date the needs were identified and the date of time frame for expected outcome: 01/20/2023. 3. The UAI in the record for resident #5, dated 01/19/2023, identifies bathing, walking and stairclimbing as areas in which the resident needs help. The ISP dated 01/20/2023 in the record for resident #5 does not address these needs. 4. The ISP in the record for resident #6, dated 06/20/2022, does not include a time frame for expected outcome for any of the needs addressed. 5. The UAI in the record for resident #8, dated 09/20/2022, identifies transferring, walking and mobility as areas in which the resident needs help. The ISP dated 09/21/2022 in the record for resident #8 does not address these needs. Regarding the additional needs addressed on the ISP for resident #8, the date the needs were identified is identical to the date of time frame for expected outcome: 09/21/2022.
Plan of Correction:	All ISPs will be corrected and updated with the correct dates. Going forward all ISPs will have the correct dates. Residents ISP will be updated with all needs addressed on UAIs and corrected time frames for goals to be met. Regarding UAIs that identify stairs as needs the facility does not have any stairs. RCD and Administrator to monitor. [SIC]
Standard #:	22VAC40-73-640-A
Description:	Based on staff interviews and observations made during the medication cart audit, the facility failed to implement their plan for ensuring an accurate count of all controlled stances when medication administration changes. EVIDENCE: 1. Resident #10 has a physician?s order for Diazepam 5mg tablet, take one tablet by mouth three times daily for agitation/anxiety. 2. The Medication Administration Record (MAR) for 01/06/2023- 02/05/2023 indicates resident #10 was administered Diazepam 5mg, as prescribed. 3. The ?Resident?s-Controlled Substance Record? for Diazepam 5mg tablet, take one tablet by mouth three times daily for the 8pm medication pass documents 26 tablets remaining as of 01/30/2023 at 8pm. The bubble pack from the pharmacy containing the Diazepam 5mg for the 8pm medication pass had 27 pills remaining. 4. According to staff #6 and staff #4 there is a discrepancy in the documented number of tablets remaining versus the actual number of tablets remaining in the pharmacy bubble pack.
Plan of Correction:	RMAs will be instructed regarding administration of medications as ordered. They will also be instructed they are not to leave the facility until all Narcotic counts are corrected and facility administrator is notified. RCD and Administrator to monitor [SIC]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the medication cart audits, the facility failed to ensure all medications are administered in accordance with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Fluticasone-Almetrol 250mcg, inhale one puff into lungs twice daily for resident #5 was observed in the medication cart labeled A-cart. This medication did not contain an open date. 2. Mometasone Furoate 50mcg, spray and inhale two sprays into each nostril every day for nasal congestion for resident #6 was observed in the medication cart labeled B-cart. This medication did not contain an open date.
Plan of Correction:	Staff have previously been instructed that all medications require an open date. Cart audits have began on Fridays to ensure all medications have been dated that are open in the care. RCD and Administrator to monitor. [SIC]
Standard #:	22VAC40-73-680-M
Description:	Based on staff interview and observations made during the medication cart audits, the facility failed to have all medications ordered for as needed (PRN) administration available and stored properly at the facility for a specific resident. EVIDENCE: 1. Resident #11 has a physician?s order for Acetaminophen 250mg, take two by mouth three times daily as needed and Ibuprofen 400mg tablet, take one by mouth three times daily as needed. 2. According to an interview, staff #4 stated neither of the two abovementioned medications were available at the facility for resident #11.
Plan of Correction:	These 2 medications were discontinued due to non-use by resident. RCD will continue medication cart audits compared to MARs/Orders to ensure that all medications ordered are present in the cart. RCD and Administrator to monior. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to maintain the interior of the building in good repair. EVIDENCE: 1. In the dining area there were four- and one-half tiles missing on the floor in the areas in front of the snack and soda machines. This could present a trip hazard.
Plan of Correction:	This area of the floor was recently repaired in July 2022. Since there has been another water leak and the tiles have came loose. Plumbing is being worked on for that area now and is planned to be corrected by 2-17-23 and the tiles will be replaced by maintenance staff. Maintenance and Administrator to monitor. [SIC]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the building, the facility failed to keep all areas free from foul odors. EVIDENCE: 1. Room #5 was observed to have a strong, foul odor inside the room. 2. Room #26 was observed to have a strong, foul odor inside the room and the odor was detected outside of the room in the hallway.
Plan of Correction:	These rooms were deep cleaned. Room #5 is due to poor hygiene by resident and he has been added to reminder shower list. Room #26 has a resident who is incontinent, and it is cleaned several times per day. Will continue to clean and provide ventilation for these rooms. RCD and Administrator to monitor [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to keep clean and in good repair all furnishings, fixtures, and equipment, including furniture, sinks, toilets, bathtubs, and showers. 1. The shared bathroom between Room #26 and Room #28 was found to have a black/brown substance scattered about the floor area of the bathtub. The toilet in the same bathroom was observed to have a brown substance that appeared to be feces down the front of the toilet bowl. The floor in front of the toilet was observed to have a yellowish substance that appeared to be urine.
Plan of Correction:	This bathroom was deep cleaned by staff on second shift after it was made aware to Administrator in exit interview. All bathrooms are to be cleaned daily by staff. B Hall is to be cleaned by 2nd shift and A Hall bathrooms by 1at shift. All bathrooms will be cleaned daily. RCD and Administrator to monitor [SIC]