VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gregory's Rest Home
29255 &29271 Walker Lane
Meadowview, VA 24361
(276) 944-5350

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: May 4, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/04/2023, 8:30am to 10:35am and 06/13/2023, 3:42pm to 4:06pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/14/2023 regarding allegations in the area(s) of: Personnel, resident care and related services Number of residents present at the facility at the beginning of the inspection: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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 #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on a review of staff schedules, the facility failed to ensure the written work schedule is accurate, including job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. EVIDENCE: 1. The work schedules provided for the months of March, April and May 2023 include days of the week and shift times, but do not include job classifications of all staff working each shift and an indication of whomever is in charge at any given time. 2. The above mentioned work schedules did not include the days and hours the administrator is on site at the facility. The administrator confirmed during interview with the LI on 06/13/2023 she does serve on a full-time basis and is responsible for the day-to-day administration and management of the facility.
Plan of Correction:	In the future the facility will have posted schedule indicating, all staff and positions as well as staff person in charge. [SIC]
Standard #:	22VAC40-73-660-A-1
Complaint related:	No
Description:	Based on a tour of the building, the facility failed to ensure medications are stored in a locked area. EVIDENCE: 1. During a visit to the facility on 05/04/2023, the LI observed a paper bag containing unopened blister packs of resident medications sitting on top of the medication cart in house #1 at 9:38am. 2. The door to the room in which the medication cart and bag of medications were located was unlocked at the time of inspection. 3. Staff #2 confirmed the medications had been delivered earlier the same morning and had not yet been put away in the locked medication cart.
Plan of Correction:	In the future medication will be promptly put up in the medication cart upon arrival. In the event it can not be put in cart the facility has implemented a locked cabinet that medication can be stored in until the Registered Medication Aide on duty can add medication to MAR and put away in cart. [SIC]