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: Feb. 7, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 02/07/2024 9:45am to 3:02pm 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: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 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 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 #:	22VAC40-73-320-B
Description:	Based on a review of resident records, the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it, for four of the five resident records reviewed. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/05/2021. The most recent TB risk assessment observed in the record for resident #1 was completed 12/12/2022. 2. Resident #2 was admitted to the facility on 08/27/2008. The most recent TB risk assessment observed in the record for resident #2 was completed 12/12/2022. 3. Resident #3 was admitted to the facility on 03/31/2003. The most recent TB risk assessment observed in the record for resident #3 was completed 12/12/2022. 4. Resident #5 was admitted to the facility on 05/10/2004. The most recent TB risk assessment observed in the record for resident #1 was completed 12/12/2022.
Plan of Correction:	All assessments will be completed with the next doctor visit. In the future, licensed administrator will monitor that all staff and resident TB risk assessments are completed and up to date in files. [SIC]
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually for three of the five resident records reviewed. EVIDENCE: 1. Resident #2 was admitted to the facility on 08/27/2008. There was no documentation of an annual review and update of the fall risk rating found in the record for resident #2. 2. Resident #3 was admitted to the facility on 03/31/2003. There was no documentation of an annual review and update of the fall risk rating found in the record for resident #3. 3. Resident #5 was admitted to the facility on 05/10/2004. There was no documentation of an annual review and update of the fall risk rating found in the record for resident #5.
Plan of Correction:	All residents have up to date fall risk rating in a newly implemented fall risk rating binder. In the future, licensed administrator will monitor for fall risk rating upon admission, annually, and as needed. [SIC]
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed at least annually for one of the five resident records reviewed. EVIDENCE: 1. Resident #5 was admitted to the facility on 05/10/2004. The most recent UAI observed in the record for resident #5 was completed on 08/22/2022.
Plan of Correction:	Currently private pay UAI completed and awaiting the public pay UAI, updated ISP per the private pay UAI. In the future, licensed administrator will document each attempt to obtain the UAI; in the event it cannot be obtained in the timely manner needed, administrator will complete a private pay UAI until public pay UAI is obtained. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on the comprehensive individualized service plan (ISP) for two of the five resident records reviewed. EVIDENCE: 1. The UAI for resident #2, dated 06/06/2023, identified dressing and toileting, human help/physical assistance, as areas in which the resident requires help. The ISP for resident #2, dated 06/06/2023, did not address these needs. 2. The UAI for resident #1, dated 08/02/2023, identified bathing, human help/supervision, as a need in which the resident requires assistance. The ISP for resident #1, dated 08/02/2023, did not address this need.
Plan of Correction:	ISPs updated to reflect all identified needs on the UAI. In the future, licensed administrator will thoroughly monitor ISPs so that all identified needs are addressed and met. [SIC]
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months for one of the five resident records reviewed. EVIDENCE: 1. Resident #5 was admitted to the facility on 05/10/2004. The most recent UAI observed in the record for resident #5 was completed on 08/22/2022.
Plan of Correction:	Currently private pay UAI completed and awaiting the public pay UAI, updated ISP per the private pay UAI. In the future, licensed administrator will document each attempt to obtain the UAI; in the event it cannot be obtained in the timely manner needed, administrator will complete a private pay UAI until public pay UAI is obtained. [SIC]
Standard #:	22VAC40-73-880-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure a space heater was used only to provide or supplement heat in the event of a power failure or similar emergency. EVIDENCE: 1. In the room for residents #3 and #4 in house #1, a portable heating unit was found to be in operation at the time of inspection. There was not a power failure or similar emergency at the time of inspection.
Plan of Correction:	Heater unplugged and stored in resident room, due to her personal property. Instructed not to use. Will discuss with the doctor due to resident states she needs it for complications from a stroke for circulation. In the future, licensed administrator will seek advice from licensing inspector prior to allowing residents to have questionable personal property. [SIC]