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: April 20, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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: 04/20/2023, 10:15am to 12:42pm 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: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 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 ensure one staff member received continuing education required by the Virginia Board of Nursing for medication aides. EVIDENCE: 1. Staff #3 started work on 11/01/2018; there was no documentation observed in the record for staff #3 verifying completion of the annual 4-hour refresher course required by the Virginia Board of Nursing for medication aides. 2. Per the trainer, staff #3 attended the training in 2021, but did not attend in 2022. Per staff #2, training for 2023 has not yet been scheduled.
Plan of Correction:	Continuing education required by the Virginia Board of Nursing is provided by the facility arrangements with a qualified trainer is scheduled yearly for staff to attend. Monitoring of staff records will be provided by supervisor to assure all training is completed. Next 4 hour training is scheduled for [SIC]
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to have a physical examination within 30 days preceding admission to the assisted living facility for one resident. EVIDENCE: 1. According to an interview with staff #1, resident #2 returned to the facility on 04/03/2023 as a resident. 2. There was no physical examination in resident #2?s file 30 days preceding his re-admission to the assisted living facility.
Plan of Correction:	A physicial exam will be obtained prior to admission for all residents. Resident had not been discharged from facility at that time, was admitted to hospital on 4-1-23 returned to facility on 4-13-23 and was re-admitted to hospital on 4-17-23. Returned to facility on 4-21-23 with all new admission forms completed at that time. Administrator will discharge all residents leaving the facility on the date they leave. [SIC]
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender and failed to document the findings and the date in the resident record for one resident. EVIDENCE: 1. According to an interview with staff #1, resident #2 returned to the facility on 04/03/2023 as a resident. 2. Resident #2?s file did not have documentation to show the facility had searched the sex offender registry for the above-mentioned resident.
Plan of Correction:	Prior to admission a potential resident is checked on the registered sex offender site and document the findings. Resident had not been discharged from facility at that time, was admitted to hospital on 4-1-23 returned to facility on 4-13-23 and was re-admitted to hospital on 4-17-23. Returned to facility on 4-21-23 with all new admission forms completed at that time. Administrator will discharge all residents leaving the facility on the date they leave. A sex offender register was in residents record prior to him leaving and a new check is in chart. [SIC]
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to gather any personal social information for one resident prior to or at the time of admission. EVIDENCE: 1. According to an interview with staff #1, resident #2 returned to the facility on 04/03/2023 as a resident. 2. Per staff #1 a personal social data information sheet was not completed upon the readmission date of 04/03/2023 for resident #2.
Plan of Correction:	Social data sheet is completed upon admission with all new admissions. Resident had not been discharged from facility at that time, was admitted to hospital on 4-1-23 returned to facility on 4-13-23 and was re-admitted to hospital on 4-17-23. Returned to facility on 4-21-23 with all new admission forms completed at that time. Administrator will discharge all residents leaving the facility on the date they leave. [SIC]
Standard #:	22VAC40-73-390-A
Description:	Based on resident record review, the facility failed to have a written agreement signed and dated by the resident or the appropriate legal representative and by licensee or administrator for one resident. EVIDENCE: 1. According to an interview with staff #1, resident #2 returned to the facility on 04/03/2023 as a resident. 2 There was no written agreement located in the file for resident #2.
Plan of Correction:	A written agreement will be signed by resident upon admission. Resident had not been discharged from facility at that time, was admitted to hospital on 4-1-23 returned to facility on 4-13-23 and was re-admitted to hospital on 4-17-23. Returned to facility on 4-21-23 with all new admission forms completed at that time. Administrator will discharge all residents leaving the facility on the date they leave. [SIC]
Standard #:	22VAC40-73-410-A
Description:	Based on resident record review, the facility failed to provide documented receipt of resident orientation for one resident. EVIDENCE: 1. According to an interview with staff #1, resident #2 returned to the facility on 04/03/2023 as a resident. 2. Staff #1 stated resident #2 did not receive resident orientation upon his return to the facility on 04/03/2023.
Plan of Correction:	Upon admission the assisted living facility shall provide an orientation for new residents. Resident had not been discharged from facility at that time, was admitted to hospital on 4-1-23 returned to facility on 4-13-23 and was re-admitted to hospital on 4-17-23. Returned to facility on 4-21-23 with all new admission forms completed at that time. Administrator will discharge all residents leaving the facility on the date they leave. [SIC]
Standard #:	22VAC40-73-430-H-1
Description:	Based on resident record review, the facility failed to provide one resident a dated discharge statement signed by the licensee or administrator upon his discharge from the facility. EVIDENCE: 1. According to an interview with staff #3 and staff #1, resident #2 was discharged from the facility on 03/31/2023. 2. Staff #1 stated she knew resident #2 would return to the facility and she did not complete a discharge statement.
Plan of Correction:	A dated discharge record will be completed when a resident leaves the facility. Administrator will complete the discharge record on the date they leave the facility. [SIC]
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review, the facility failed to develop a preliminary plan of care on or within seven days prior to the admission for one resident. EVIDENCE: 1. According to an interview with staff #1, resident #2 returned to the facility on 04/03/2023 as a resident. 2. The file for resident #2 did not contain a preliminary plan of care.
Plan of Correction:	A plan of care will be developed on or within seven days prior to admission for new admissions. Resident had not been discharged from facility at that time, was admitted to hospital on 4-1-23 returned to facility on 4-13-23 and was re-admitted to hospital on 4-17-23. Returned to facility on 4-21-23 with all new admission forms completed at that time. Administrator will discharge all residents leaving the facility on the date they leave. [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 one of the resident files that were reviewed. EVIDENCE: 1. The UAI dated 11/14/2022 in the record for resident #1 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.
Plan of Correction:	Description of all identified needs and date identified will be noted on ISP, incontinence needs were added to UAl. Administrator will monitor resident ISP's to assure all identified needs are listed. [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. The stairs leading to the basement appeared dirty with dark spots and particles of dirt on each of the steps. 2. A corner ceiling tile in basement bathroom #14 appeared to have a brown water stain over approximately 75 percent of the tile. 3. The tile flooring in basement bathroom #14 appeared dirty with dark spots throughout. 4. The trash can in basement bathroom #14 was full. 5. Six of the ceiling tiles over the dining table in the basement common area appeared to have brown water stains covering anywhere from approximately 10 to 60 percent of the respective tiles. 6. The tile flooring in basement bathroom #16 appeared dirty with dark spots throughout. 7. The trash can in basement bathroom #16 was full and overflowing. 8. The tile flooring in basement bathroom #18 appeared dirty with dark spots, especially in front of the toilet. 9. The trash can in basement bathroom #18 was full. 10. The tile flooring in the basement hallways and common areas appeared dirty with dark spots, some resembling coffee stains, throughout. 11. The tile flooring near the entrance of resident room #27 appeared dirty with dark stains and spots covering approximately 16 square tiles. 12. The black throw rugs in from of the exit doors in the basement and upstairs in the sunroom were found to have specks of dirt and lint scattered about, appearing as if they had not been vacuumed. 13. The flooring in resident room #12 appeared dirty with several dark spots, some resembling coffee stains, by the bed closest to the door. Under the same bed were what appeared to be several small pieces of popcorn. 14. The flooring in the sunroom appeared dirty with dark spots and particles of dirt throughout. 15. The tile flooring in bathroom #5 appeared dirty, especially in front of the toilet. The space where the tiles meet the flooring under the toilet appeared to be covered with a dark/black substance. 16. The trash can in bathroom #5 was full and overflowing. 17. A brown substance was observed in the floor of ladies bathroom #8, resembling feces, near the first stall. 18. A clump of toilet tissue was observed in the floor by the toilet in shower room #10 with a brown substance on it, resembling feces. 19. The LI observed what appeared to be four unused disposable underwear and two unused sanitary pads in the floor of ladies restroom #11. 20. The flooring in men?s bathroom #9 appeared dirty with several dark spots in front of the sink and the first urinal.
Plan of Correction:	Facility will ensure the interior and exterior of all buildings shall be maintained in good condition and kept clean and free of rubbish. Housekeeping staff that was hired is no longer available for work. Office manager is advertising job positions opened and will hire new staff for the housekeeping position. All other staff are picking up the extra work until positions are filled. [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. EVIDENCE: 1. Resident room #9 had a very strong foul odor present when LI walked into the room. 2. Ladies bathroom #8 had a very strong foul odor present when LI walked into the room.
Plan of Correction:	Facility will ensure all buildings shall be well-ventilated and free from foul, stale and musty odors. Housekeeping staff that was hired is no longer available for work. Office manager is advertising job positions opened and will hire new staff for the housekeeping position. All other staff are picking up the extra work until positions are filled. [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 and bowl of the toilet in basement bathroom #14 were soiled with light and dark brown spots, resembling urine and feces. 2. The rim and bowl of the toilet in basement bathroom #16 was soiled with brown spots, resembling feces. 3. The bowl and base of the toilet in basement bathroom #18 was soiled with dark yellow/light brown spots. 4. The fabric on the seats of the blue and dark green chairs and the blue floral sofa in the basement common area appeared to be soiled with dark spots and a white substance. 5. The rim and bowl of the toilet in bathroom #5 was soiled with dark spots resembling feces. The same toilet appeared unflushed and the water was dark yellow. 6. The seat and bowl of the first and second toilets in ladies bathroom #8 were soiled with a dark brown substance resembling feces. The second toilet appeared unflushed and the water was brown. 7. The back portion of the seat of the third toilet in ladies bathroom #8 appeared stained with a dark yellow substance. 8. A recliner was observed to be overturned in the sunroom. A resident stated ?someone peed in it.? Staff #1 reports the recliner was overturned so no other residents will use it until it is cleaned.
Plan of Correction:	The facility will ensure all furnishings, fixtures and equipment shall be kept clean and in good repair and condition. Housekeeping staff that was hired is no longer available for work. Office manager is advertising job positions opened and will hire new staff for the housekeeping position. All other staff are picking up the extra work until positions are filled. [SIC]
Standard #:	22VAC40-73-925-A
Description:	Based on a tour of the building, the facility failed to ensure an adequate supply of toilet tissue, accessible to each commode. EVIDENCE: 1. The toilet tissue dispenser in basement bathroom #14 was empty; the LI did not observe toilet tissue elsewhere in the room.
Plan of Correction:	The facility will ensure that there is adequate supply of toilet tissue accessible to each commode. Housekeeping staff that was hired is no longer available for work. Office manager is advertising job positions opened and will hire new staff for the housekeeping position. All other staff are picking up the extra work until positions are filled. Maintenance will supply all toilet tissue in each bathroom each morning and check each evening to assure all commodes has adequate supply of tissue until Housekeeping positions are filled. [SIC]