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: Jan. 3, 2024 and Jan. 4, 2024

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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/03/2024, 10:15am to 4:05pm and 01/04/2024, 9:50am to 5:15pm. 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 14 Number of staff records reviewed: 14 Number of interviews conducted with residents: 4 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 #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to obtain the results of the annual tuberculosis (TB) risk assessment for one of the five staff records reviewed. EVIDENCE: 1. Staff #5 started work on 09/02/2019. 2. The most recent report of TB risk assessment observed in the record for staff #5 was dated 06/10/2022. 3. Staff #15 was unable to locate a more recent report of TB risk assessment for staff #5.
Plan of Correction:	All TB risk assessments will be completed annually. Administrator, RCD and Administrator Assistant to monitor [SIC]
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure the report of physical examination contained all required information within the timeframe of 30 days preceding admission for one of the 14 resident records reviewed. EVIDENCE: 1. Resident #3 was admitted to the facility 08/03/2023. 2. The Virginia Tuberculosis (TB) Screening and Risk Assessment Tool for resident #3 was completed 05/30/2023, 64 days prior to admission.
Plan of Correction:	All new admissions will have a TB Risk assessment within 30 days prior to admission to facility Administrator to monitor [SIC]
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to obtain all required personal and social information prior to or at the time of admission for one of the 14 resident records reviewed. EVIDENCE: 1. Resident #5 was admitted to the facility on 11/27/2023. 2. The Personal/Social Data form in the record for resident #5 did not contain information regarding current behavioral and social functioning, strengths and problems.
Plan of Correction:	All paperwork including the social and data sheets will be completed on day of admission from the day forward. Administrator, RCD and Administrator Assistant to monitor. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure the comprehensive individualized service plan (ISP) included all required information for two of the 14 resident records reviewed. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident #2 completed 02/2023 identified the following areas in which resident #2 requires assistance: meal preparation, housekeeping, laundry, money management, transportation, shopping, and home maintenance. The ISP for resident #2 completed 02/27/2023 contained no time frame for expected outcomes regarding the needs identified above. 2. The UAI for resident #4 completed 11/01/2023 identified the following areas in which the resident requires mechanical help only: bathing, toileting, transferring, walking, stairclimbing, and mobility. The ISP for resident #4 completed 11/04/2023 had the word ?mechanical? written by each of the needs noted above, but did not specify exactly what type of mechanical help will be used to aid resident #4 with the identified needs.
Plan of Correction:	ISPs will be completed on admission and annually and reviewed as needed throughout resident stay at the facility and changes and updates made accordingly. RCD and administrator to monitor [SIC]
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records, the facility failed to ensure the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order, and to organize orders chronologically in the record for one of the 14 resident records reviewed. EVIDENCE: 1. The Medication Administration Record (MAR) for resident #13, dated 12/08/2023 to 01/07/2024, indicates resident #13 is receiving Duloxetine 60mg capsule, one capsule by mouth every day for depression. 2. Duloxetine 60mg capsules for resident #13 were observed in the medication cart on the date of inspection. 3. The order for the medication could not be found in the record for resident #13 on the date of inspection. 4. Staff #15 contacted the pharmacy and documentation of the provider?s oral order for Cymbalta 60mg QD dated 10/25/2023 was faxed to the facility on the date of inspection.
Plan of Correction:	Charts are to be reviewed monthly by all RMAs and RCD to ensure that all orders and charts are up to date along with orders being chronologically in order RCD and Administrator to monitor [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure each bedroom contains all required items. EVIDENCE: 1. The bedside lights in resident room #33 were not operable; they did not work when switched on during the date of inspection. 2. The licensing inspector (LI) did not observe any chairs in resident rooms #20, #26 and #37. 3. There are two residents assigned to room #22 and only one chair was observed in the room on the date of inspection.
Plan of Correction:	Lights in rooms will be inspected monthly and repaired as needed to maintain compliance with each resident having a beside light or lamp. Maintenance, RCD, Administrator to monitor. All residents will have their own personal chair available to them upon admission to the facility. If residents do no bring or provide their own personal chair, a sturdy chair will be provided to them from the facility. Rooms will be inspected weekly for compliance. DC supervisor, RCD and Administrator to monitor [SIC]
Standard #:	22VAC40-73-860-D
Description:	Based on observations made during the tour of the building, the facility failed to have all operable windows effectively screened. EVIDENCE: 1. The screen in the window on the right in the A hallway sitting area was separated from the frame in the lower right corner, and had a hole approximately the size of a quarter on the lower right side. 2. In resident room #34, the window on the right was not screened. 3. In resident room #33, the windows were not screened. There was one screen propped up against the building in front of the window on the left.
Plan of Correction:	Screens will be replaced, and all screens will be operable to maintain compliance. Maintenance will inspect windows monthly and monitor. Maintenance, RCD and Administrator to monitor [SIC]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, the facility failed to ensure hot water at taps available to residents is maintained within a temperature range of 105-120 degrees Fahrenheit. EVIDENCE: 1. In resident room #22, the hot water at the bathroom sink reached a temperature of 133.5 degrees Fahrenheit. 2. In resident room #27, the hot water at the bathroom sink reached a temperature of 139.5 degrees Fahrenheit. 3. In resident room #37, the hot water at the bathroom sink reached a temperature of 92.2 degrees Fahrenheit.
Plan of Correction:	Water temps will be corrected immediately. All water temps are to be monitored monthly with written checks completed by the 5th of each month. Maintenance, RCD and Administrator to monitor. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the 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. 1. The paint on the walls behind and to the right of the toilet in the bathroom for resident room #20 was observed to be chipped and peeling. 2. The door leading to the bathroom for resident room #16 appeared dirty with dark stains above and below the doorknob. 3. The floor in the bathroom for resident room #12 appeared dirty with dark spots covering two tiles in front of the toilet. 4. The door in the bathroom that opens to resident room #10 had a dark thick line across the bottom, approximately eight inches from the floor. 5. The floor in the bathroom for resident room #8 appeared dirty with dark spots covering portions of six tiles in front of and beside the toilet. 6. The door leading to the bathroom for resident room # 9 appeared dirty with dark stains above, below and directly to the left of the doorknob. 7. The bathroom door and doorframe leading to resident room #11 was observed to have chipped paint and dark lines across the bottom portion. 8. The inside of the door for resident room #11 appeared dirty with dark spots and had areas of chipped and peeling paint above, below and around the doorknob. 9. The bottom half of the door to the laundry room had chipped and peeling paint and scuff marks. 10. Black areas were observed on the ceiling to the left and right of the light fixture above the entrance to the A hallway. 11. The paint on the frame of the bathroom door leading to resident room #21 appeared to be rusting and chipped on the bottom left side. 12. The paint on the bathroom wall to the right of the toilet in resident room #33 was peeling near the base and there was a black vertical streak above that area approximately 15 inches in length. There were also rust colored and other dark spots on the portion of the wall under the toilet paper dispenser.
Plan of Correction:	All bathrooms and bedrooms shall be painted where there is chipped paint. Doors and windows are to be wiped down weekly. Housekeeping to bathrooms (Sinks, toilets, floors are to be cleaned daily), (Showers/tubs biweekly). Maintenance, housekeeping, RCD and Administrator to monitor [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the 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 water in the toilets in resident rooms #27 and #37 sounded as if it were running constantly. 2. The bathtub for resident room #33 had a crack on the outside portion approximately five inches in length and an area below and to the left of the shower head that had several small cracks that had previously been covered by what appeared to be a dark brown caulk or putty.
Plan of Correction:	Bathroom fixtures will be in good/working condition and remain free from cracks, breaks or will be replaced. #37 toilet fixed 1/08/2024. #33 bathtub will have to be replaced. Maintenance to monitor fixtures weekly. Maintenance, RCD, Administrator and Licensee to monitor compliance [SIC]
Standard #:	22VAC40-73-890-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure all interior areas shall be adequately lighted for the safety and comfort of residents and staff. EVIDENCE: 1. In the bathroom for resident room #27, one of the two fluorescent bulbs in the light fixture near the shower was not working, making the shower area dimly lit.
Plan of Correction:	All light fixtures will be in good working order with adequate lighting. #27 fixture will be replaced. Maintenance, RCD, Administrator and Licensee to monitor. [SIC]
Standard #:	22VAC40-73-920-C
Description:	Based on observations made during the tour of the building, the facility failed to ensure ventilation to the outside in order to eliminate foul odors in all bathrooms. EVIDENCE: 1. In resident rooms #16, #12 and #37, the bathroom exhaust fan did not appear to be in working order as it made no sound when switched on.
Plan of Correction:	All exhaust fans will remain in good working order or will be replaced. Exhausts in #16, #12, #37 will be repaired. Maintenance, RCD, Administrator, Licensee to monitor [SIC]
Standard #:	22VAC40-90-40-F
Description:	Based on a review of staff records, the facility failed to ensure a criminal history record report issued by the State Police shall not be accepted by the facility if the report is dated more than 90 days prior to the date of employment, for one of the staff records reviewed. EVIDENCE: 1. Staff #8 was rehired by the facility on 11/06/2023. 2. The facility previously requested a criminal history report on 03/30/2023 and it was provided to the facility with a date of 04/21/2023. 3. The facility did not request a new criminal history report for staff #8 upon rehire, and the previously received report was dated more than 90 days prior to the date of employment.
Plan of Correction:	Staff #8 background check resent to VSP regarding new check and in the future all new employees will have new background checks. Administrator, RCD to monitor compliance [SIC]