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: July 10, 2023 and July 18, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 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: 07/10/2023, 1:35pm to 2:20pm and 07/18/2023, 3:02pm to 3:13pm 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 04/27/2023 regarding allegations in the area(s) of: Admission, retention and discharge of residents Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A 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 supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also 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 #:	22VAC40-73-310-A
Complaint related:	Yes
Description:	Based on information received in a complaint and a review of resident records, the facility failed to ensure no resident shall be admitted or retained who requires a level of care for which the facility is not licensed. EVIDENCE: 1. LI received a call from collateral #1 on 04/27/2023 reporting concerns that resident #1 was admitted to a facility licensed to provide residential living care only, when the resident was rated dependent in four of seven activities of daily living (ADLs) on the Uniform Assessment Instrument (UAI). 2. Per 22VAC30-110-60, individuals shall meet the criteria for residential living as documented on the UAI when rated dependent in only one of seven ADLs (i.e., bathing, dressing, toileting, transferring, bowel function, bladder function, and eating/feeding). 3. Per 22VAC30-110-70, individuals shall meet the criteria for assisted living as documented on the UAI when rated dependent in two or more of seven activities of daily living (ADLs). 4. On the UAI for resident #1, completed 04/25/2023, the resident was rated dependent in four of seven ADLs: bathing (mechanical and human help, physical assistance), dressing (mechanical and human help, physical assistance), toileting (mechanical and human help, supervision) and transferring (mechanical and human help, supervision). 5. Resident #1 was admitted to the facility on 04/25/2023; the facility is licensed to provide residential living care only.
Plan of Correction:	Before any resident is admitted their UAI will be reviewed to make sure they are not dependent in more than 1 ADL. [SIC]