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: April 17, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

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: 04/17/2023, 9:53am to 12:34pm 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: 7 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 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 #:	22VAC40-73-680-H
Description:	Based on a review of medication administration records (MARs) and interviews with staff, the facility failed to document on the MAR all medications administered to residents, including over-the-counter medications and dietary supplements, for two resident records reviewed. EVIDENCE: 1. There were no staff initials on the MAR for resident #1 indicating the following medications were given on 04/16/2023: Acetaminophen Arthritis Er 650 Mg Cplt, 9am dose; Aspirin Ec 81 Mg Tablet, 9am dose; Benztropine Mes 0.5 Mg Tab, 9am dose; Escitalopram 20 Mg Tablet, 9am dose; Ferrous Sulfate 325 Mg Tablet, 9am dose; Hydralazine 10 Mg Tablet, 7am and 3pm doses; Meclizine 12.5 Mg Caplet, 7am and 3pm doses; Memantine Hcl 10 Mg Tablet, 9am dose; Pantoprazole Sod Dr 20 Mg Tab, 9am dose; Propanolol 10 Mg Tablet, 7am, 3pm and 11pm doses; Quetiapine Fumarate 25 Mg Tab, 9am dose; Vitamin B-12 1,000 Mcg Tablet, 9am dose; Vitamin D3 2,000 Unit Tablet, 9am dose; Lisinopril-HCTZ 10-125 Tab, 9am dose. 2. There were no staff initials on the MAR for resident #1 indicating the following medication was administered on 04/13/2023: Lisinopril-HCTZ 10-125 Tab, 9am dose. 3. There were no staff initials on the MAR for resident #2 indicating the following medications were given on 04/16/2023: Basaglar 100 Unit/Ml Kwikpen, 8am dose; Buspirone Hcl 15 Mg Tablet, 8am dose; Calcium 600 Mg-Vit D3 10mcg Tb, 8am dose; Calcium Antacid 500 Mg Chw Tab, 8am dose; Carvedilol 25 Mg Tablet, 8am and 4pm doses; Diazepam 5 Mg Tablet, 8am and 4pm doses; Duloxetine Hcl Dr 60 Mg Cap, 8am dose; Enalapril Maleate 20 Mg Tab, 8am dose; Ferrous Gluconate 324 Mg Tab, 8am dose; Furosemide 40 Mg Tablet, 8am and 1pm doses; Incruse Ellipta 62.5 Mcg Inh, 8am dose; Levetiracetam 750 Mg, 8am dose; Loratadine 10 Mg Tablet, 8am dose; Meclizine 25mg tablet, 8am and 4pm doses; Metformin Hcl Er 500 Mg Tablet, 8am and 4pm doses; Novolog Flexpen Syringe, 7am, 12pm and 5pm doses; Pantoprazole Sod Dr 40 Mg Tab, 8am dose; Topiramate 100 Mg Tablet, 8am dose; Vitamin B-12 1,000 Mcg Tablet, 8am dose; Vitamin D3 2,000 Unit Tablet, 8am dose; Ammonium Lactate 12% Lotion, 8am application; Ammonium Lactate 12% Lotion, once daily application. 4. There were no staff initials on the MAR for resident #2 indicating the following medication was administered on 04/14/2023 and 04/15/2023: Novolog Flexpen Syringe, 5pm doses.
Plan of Correction:	All RMAs have been instructed to fill in MARs as they go and must review MARs and initials to ensure completion of charting. If medication is not administered or refused must be charted on the MAR while still with the resident. Each Friday MARs are to be reviewed by RCD to ensure compliance. RCD and Administrator to monitor [SIC]