VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greenfield Reflections of Woodstock
1222 S. Ox Road
Woodstock, VA 22664
(540) 459-2200

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: May 4, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

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: 5/4/2023 The Acknowledgement of Inspection form was signed and left at the facility on the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. There were no issues identified with internal physical plant. The building was clean and odor free. The issue relating to the grounds is addressed in the violation notice. Number of resident records reviewed: 11 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Primary outside inspections were current. Violations related to other outside inspections and related drills are noted in the violations portion of this report. The residents were observed as actively engaged at various times throughout this inspection process. Residents were clean and neatly dressed. Postings were as required and appeared to be followed. The administrator has completed AIT and is preparing to sit for her licensing exam. Additional Comments/Discussion: Fire ? 4/20/23 Health ? 10/31/22 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with six applicable standard(s) or law, and violations 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 violations. will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov Thank you to staff and residents for your cooperation during this monitoring inspection process.

Violations:

Standard #:	22VAC40-73-1050-A
Description:	During a walk thru of the facility and the surrounding secured outside the area, the area was found to not be secure as the lock and the gate were broken. A cinder block had been placed on the outside of the gate, but it was noted the locking mechanism did not work as the gate was not on the hinges correctly.
Plan of Correction:	Maintenance has addressed this and repaired. Staff has been told not to use that gate as an exit. Administrator and maintenance will continue to monitor for compliance.
Standard #:	22VAC40-73-1090-A
Description:	Based on a review of nine resident records, none of the nine records were found to be complete. None of the residents admitted at the end of 2022 or in 2023 had a serious cognitive impairment form, approval for placement or appropriateness of placement form. Appropriateness of placement forms had not been completed for those individuals admitted prior to that time. The review further indicated that there was no documentation of annual TB tests as applicable, resident rights, initial orientation, the service plans for residents D and E were expired along with UAIs and the UAI for resident F was also expired. The file for resident C admitted 4/26/23 was empty except for the physical and TB test. Sex offender reviews were also missing
Plan of Correction:	All files are being reviewed and required paperwork being secured. A checklist is being developed to ensure all new admission paperwork is complete. The administrator along with assigned staff assume responsibility for correction and future compliance.
Standard #:	22VAC40-73-1140-B
Description:	Based on a review of six staff files there was no documentation to indicate staff had received the required training in cognitive impairment.
Plan of Correction:	The administrator is working with facility training program to ensure the required training is: 1. Eligible at time of hire 2. Monitored to ensure completion. For current staff they have begun training immediately to be current with the standards. The administrator and RCC assume responsibility for correction and future compliance.
Standard #:	22VAC40-73-250-C
Description:	Based on a review of six staff files, the files were found to be incomplete as it relates to various items: missing or expired annual TB tests, missing, or expired annual resident rights, no job description, staff signed orientation, and missing background checks.
Plan of Correction:	Staff have been working diligently to review all staff records and bring them into compliance. The issue related to not being able to run background checks has been corrected via assistance from a sister facility and all are current. Additional paperwork is being completed as applicable. A checklist is being developed to further ensure compliance with new hires as well as current staff. The administrator with the assistance of the RCC are working on corrections and assume responsibility for future compliance.
Standard #:	22VAC40-73-490-A
Description:	The facility had no documentation of a health care oversight in the last six months. For facilities with assisted living level of care residents the facility is required to have a health care oversight every three months or every six months if employ a healthcare professional full time working within their scope of practice. The administrator in training is a licensed practical nurse but does not practice primarily in the scope of that profession.
Plan of Correction:	The person previously providing oversight is no longer with the company. The administrator is contacting the pharmacy to see if they can assist with this process. The administrator will also reach out to a nurse at another facility. The administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-970-A
Description:	There was no documentation of fire drills for January through March 2023. The facility did have drills for the prior quarter and had conducted one for April 2023.
Plan of Correction:	Previous missing drills cannot be corrected but going forward the administrator assumes responsibility for future compliance in conjunction with other assigned staff.