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: March 8, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 03/08/2023, 8:40am to 3:54pm 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: 57 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: 4 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 #:	22VAC40-73-210-D
Description:	Based on a review of staff records, the facility failed to maintain documentation of continuing education required by the Virginia Board of Nursing for medication aides for one of the five staff records reviewed. EVIDENCE: 1. Staff #4 started work on 11/01/2018; there was no documentation observed in the record for staff #4 verifying completion of the annual 4-hour refresher course required by the Virginia Board of Nursing for medication aides. 2. Staff #4 reported receiving the training referenced above, but had no documentation available on date of inspection to verify completion of the training. 3. Staff #6 contacted the instructor of the 4-hour refresher course noted in item #1; the instructor agreed to provide documentation verifying staff #4?s completion of the course, however this documentation was not received by end of date of inspection which occurred on 03/08/2023.
Plan of Correction:	Continuing education required by the Virginia Board of Nursing for medication aides shall be retained in aides staff file. A copy of the required training has been provided and is in staff record. Administrator designee will monitor the staff records to assure all required training is documented, copies are kept in file. [SIC]
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to obtain an initial tuberculosis examination or results of a tuberculosis risk assessment and report for one of the five staff records reviewed. EVIDENCE: 1. Staff #1 started work on 01/12/2023; there were no results of a risk assessment observed in the record for staff #1 documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. There was a Report of Tuberculosis Screening Evaluation form observed in the record for staff #1, however, only the name, address and birthdate sections were completed.
Plan of Correction:	Health information required by standards shall be maintained at the facility an be included in the staff record for each staff person within seven days prior to coming in contact with residents. Adm designee will monitor staff files for compliance [SIC]
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records, the facility failed to complete an annual risk assessment for tuberculosis as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for one of the nine resident records reviewed. EVIDENCE: 1. Resident #8 was admitted to the facility on 10/13/2017; there was no annual risk assessment for tuberculosis observed in the record for resident #8. The most recent annual tuberculosis risk assessment observed in the record for resident #8 was dated 04/17/2021.
Plan of Correction:	A risk assessment for tuberculosis shall be completed annually on each resident, # 8 assessment had been completed on 4-27-22 and had been misfiled in her chart. DON will file these annually to assure that it is filed under the correct tab. [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 nine resident files that were reviewed. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) dated 10/12/2022 in the record for resident #1 identifies shopping as an area in which the resident needs help. The ISP dated 10/12/2022 in the record for resident #1 does not address this need. 2. The UAI dated 11/14/2022 in the record for resident #6 does not identify continence (bowel and bladder) as a need. However, in the section directly to the right, incontinent less than weekly (bowel) and incontinent weekly or more (bladder) are selected. The ISP dated 01/06/2023 in the record for resident #6 does not address these needs. 3. The UAI dated 01/11/2023 for resident #7 identifies walking, mechanical help only, as a need. The ISP dated 01/11/2023 in the record for resident #7 does not address this need.
Plan of Correction:	The comprehensive individualized service plan shall be completed and address all identified needs on the ISP. Needs for resident #1, #6, and #7 have been corrected on ISP. Administrator and DON will monitor ISP's monthly to assure all needs are addressed. [SIC]
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records, the facility failed to maintain written acknowledgement of annual review of rights and responsibilities of residents in assisted living facilities for one of the nine resident records reviewed. EVIDENCE: 1. Resident #2 was admitted to the facility on 02/15/2013; there was no documentation acknowledging annual review of resident rights and responsibilities observed in the record for resident #2. The most recent acknowledgement of annual review of resident rights and responsibilities observed was dated 01/28/2022.
Plan of Correction:	The rights and responsibilities of residents in assisted living facilities shall be reviewed annually and evidence of this review shall be filed in the resident's record. Resident #2 had been completed on 01-25-23 and was misfiled. DON will file these annually to assure that it is filed under the correct tab. [SIC]
Standard #:	22VAC40-73-650-E
Description:	Based on observations made during the noon medication pass and review of resident records, the facility failed to have physician orders organized chronologically in the resident?s record. EVIDENCE: 1. Resident # 10 had a discontinue order to obtain blood pressure checks dated for 02/01/2023. This was noted on the March 2023 Medication Administration Record (MAR), but the order was not found to be chronologically filed in the resident record. The facility had the pharmacy fax the order on the date of the inspection. 2. Resident # 11 had physician?s orders for the following medications: Hydroxyzine HCL 25mg tablet, take one tablet by mouth three times daily; Imipramine HCL 25 mg tablet, take one tablet by mouth twice daily; Melatonin 5mg, take one tablet by mouth at bedtime and Vitamin D3 1000 unit, take one tablet by mouth daily. These medications were all recorded on the MAR and were being administered. The facility did not have the corresponding physician?s orders filed chronologically in the resident?s file. The facility had the pharmacy fax the order on the date of the inspection.
Plan of Correction:	The residents record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's order. Orders shall be organized chronologically in the resident's record. DON will monitor physician orders and file in resident record daily as they are received. [SIC]
Standard #:	22VAC40-73-680-E
Description:	Based on observations made during the noon medication pass, the facility failed to carry out treatments ordered by a physician according to prescriber?s instructions for one resident. EVIDENCE: 1. Resident # 12 is prescribed Baby Powder/corn starch to apply topically two times daily for yeast in the left groin. This medication was not able to be located at the facility during the medication pass.
Plan of Correction:	Medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the residents record. Baby Powder/corn starch was obtained and placed in med cart for resident # 12 that day. Med Techs will monitor med cart daily to assure all treatment medication is present, ordering refills prior to medication running out to assure all medications are at facility. [SIC]
Standard #:	22VAC40-73-680-I
Description:	Based on observations made during the noon medication pass and review of resident records, the Medication Administration Record (MAR) did not include the correct strength of the drug for one resident. EVIDNCE: 1. Resident # 13 had a physician?s order dated 03/01/2023 for Quetifumanate 300 mg, one by mouth at bedtime and 50mg by mouth one time daily. The MAR for March 2023 had this listed as Quetifumanate 100mg, take ? tablet by mouth in the morning and one tablet at bedtime. The medication pack from the pharmacy did contain the correct dosage/strength.
Plan of Correction:	The MAR shall include the strength of the drug, Med Techs will monitor the MAR matching the order with the medication pack and the MAR at each medication pass. DON will check meds to MAR monthly for accuracy. [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure each resident room contained the required items. EVIDENCE: 1. Resident rooms #5, #6, #8, #9, #10, #12, #22 has two residents assigned to the room, there was only one chair available in each room. 2. Resident rooms #4, #5 and #6 has two residents assigned to the room, there was only one bedside lamp available in each room.
Plan of Correction:	An operable bed lamp or bedside light accessible to each resident, a sturdy chair for each resident shall be provided for each resident. Two chairs are provided in rooms 5, 6, 8, 9, 10, 12, 22 and bedside lamps in rooms 4, 5, 6. Housekeeping will monitor rooms daily to assure all rooms have chairs and operable lamp for each resident. Housekeeping will notify maintenance for missing objects. [SIC]
Standard #:	22VAC40-73-750-E
Description:	Based on observations made during the tour of the building, the facility failed to have sufficient bed linens in good repair and clean, so residents always have clean linen items. EVIDENCE: 1. In resident room #12 the bed linens on the bed under the window were found to be unclean and stained and the linens for the bed closest to the door were observed to be stuffed under the bed. 2. The bed closest to the door in resident room #4 was found to have no bed sheets on the bed, the resident stated he wets the bed and he does not use sheets. 3. Resident room #6 was found to have no bed sheets on the bed closest to the door. There was a black trash bag covering the top half of the mattress where the resident had her head laying. During the inspection, the resident stated she wanted sheets and a blanket but wasn?t sure why she didn?t have these items.
Plan of Correction:	The facility shall have sufficient bed and bath linens in good condition so that resident always have clean sheets, pillowcases, blankets, bedspread, towels, washcloths and waterproof mattress covers when needed. Direct Care Staff will notify Administrator when supply runs low and it will be replaced. [SIC]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, 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. The women?s common bathroom off the sunroom, the hot water at the bathroom sink reached a temperature of only 83.9 degrees Fahrenheit. 2. The men?s common bathroom off the sunroom, the hot water at the bathroom sink reached a temperature of only 80.9 degrees Fahrenheit.
Plan of Correction:	Hot water at taps available to residents will be maintained within range of 105 degrees to 120 degrees. Maintenance will monitor water temperatures and adjust hot water heater to maintain 105-120 degree temperature. Water temperature will be taken thru out the day. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. A corner ceiling tile in basement bathroom #14 appeared to have a brown water stain over approximately 60 percent of the tile. 2. The tile flooring in basement bathroom #14 appeared dirty with dark spots throughout and especially in the area directly in front of the toilet. 3. The tile flooring in basement bathroom #16 appeared dirty with dark spots throughout. 4. The baseboards behind and beside the toilet in basement bathroom #16 appeared dirty with dust on the top portion of the baseboards. 5. The tile flooring in basement bathroom #18 appeared dirty with dark spots, especially in front of and beside the toilet. 6. The tile flooring in the basement hallways and common areas appeared dirty with dark spots, some resembling coffee stains, throughout. 7. The tile flooring in resident room #27 appeared dirty with dark spots, especially in the areas in front of the mini refrigerator and next to the bed. 8. Resident room #4 had a pile of swept up dirt lying in the floor next to the door. The pile of dust and dirt had not been collected but left lying. 9. Resident room # 5 floor was found to be dirty with particles of trash and clothes under the bed closest to the door. There was also a urinal on a clear storage tote which was ? full with gnats flying around the open lid area. There were no residents present in the room at the time the LI observed the room. 10. Resident room #6 had Styrofoam cups and five tissues under the bed near the door. 11. The telephone room had black marks on more than half of the floor surface, appearing as if it had not been mopped for some time. 12. The floor in resident room #8 appeared as if it had not been mopped in some time. 13. Resident room #9 had visible coffee-colored stains on the floor and trash scattered about the entire room.
Plan of Correction:	The interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Two new cleaning staff have been added to schedule, maintenance is in charge of keeping floors clean and free of black marks by running floor cleaning machine daily and as needed. [SIC]
Standard #:	22VAC40-73-870-B
Description:	Based on a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. 1. Basement bathroom #18 had a strong odor resembling urine when LI walked into the room. 2. Resident room #27 had a strong foul odor present with LI walked into the room. 3. Resident room #9 had a very strong foul odor present when LI walked into the room. 4. Resident room #19 had a very strong odor resembling urine when LI walked into the room. 5. The men?s common bathroom #10 had a very strong odor resembling urine present when LI walked by the door.
Plan of Correction:	All buildings shall be well-ventilated and free from foul, stale and musty odors. By adding new cleaning staff the building no longer has foul odors, facility will continue to keep 3 housekeepers on staff to maintain clean odor free environment. Administrator will monitor for odors and address with staff if necessary. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on a tour of the building, the facility failed to ensure all furnishings, fixtures and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. The rim around the toilet in basement bathroom #14 was soiled with brown spots, resembling feces. 3. The rim and seat of the toilet in basement bathroom #16 was soiled with brown spots, resembling feces. 4. The toilet bowl basement bathroom #18 appeared stained with a brown substance covering approximately 30 percent of the lower portion of the bowl. 5. There were two used/wet washcloths observed in the floor of the shower in basement bathroom #18. 6. The fabric on the seats of the blue and dark green chairs in the common area shared by residents appeared to be soiled with dark spots and a white substance. 7. The sunroom had a black scatter rug in front of the glass door leading to the smoking porch that was found to have specks of dirt and lint scattered about, appearing as if it had not been vacuumed. 8. The women?s common bathroom across from the dining area had at least three piles of tissue paper laying in the floor of the third stall when LI entered. 9. The same common women?s bathroom had not been cleaned in the second stall. It was found to have a toilet full of feces which had not been flushed that had splashed out of the toilet bowl and onto the wall surrounding the toilet. 10. Resident room #9 had wet and soiled sheets on the bed. The LI observed a used adult pull-up laying on the sheet which had been soiled. 11. The men?s common bathroom #10 was found to have gnats swarming around the entrance door, the floor was sticky, there were black shoe prints on more than half of the surface of the floor and gnats were surrounding the urinal closest to the door.
Plan of Correction:	All furnishings, fixtures, and equipment including furniture, window coverings, sinks, toilets, bathtubs and showers will be kept clean and in good repair and conditioning and in safe condition and not soiled in a manner that presents a health hazard. Housekeeping staff will keep all toilets and furnishings clean daily, report to maintenance when repairs and replacement are needed. Housekeeping will monitor bathrooms numerous times during the day to assure they are clean and odor free, door rugs are vacuumed daily and replaced weekly by company, housekeeping is making beds daily assuring sheets and bedspreads are clean. [SIC]