VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Angela N Via (540) 682-1739

Inspection Date: April 7, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

None

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: 4/7/2025, 4:00pm-4:45pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. complaint was received by VDSS Division of Licensing on 2/7/2025 regarding allegations in the area(s) of: Incidents and admission and retention of residents. Number of residents present at the facility at the beginning of the inspection: 26 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector reviewed, incident reports, rounding logs and communication logs. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Jessica Gale Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that prior to his admission to a safe, secure environment, the resident had been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident 1 was admitted 1/8/2025 into a safe, secure environment. 2. Upon request the facility failed to provide an assessment of serious cognitive impairment for resident 1. 3. During an interview with staff 1, when asked if there was an assessment for serious cognitive impairment for resident 1, staff 1 answered ?no?.
Plan of Correction:	All potential residents will have an Assessment of Serious Cognitive impairment completed prior to admission.
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that had negatively affected or that threatened the life, health, safety, or welfare of any resident. Evidence: 1. Record review for resident 1 showed an incident that occurred on 2/5/2025 involving resident 1, resulting in resident 1 being transported to the emergency department. 2. During an interview with staff 1, when asked if the incident involving resident 1 was reported to the regional licensing office, staff 1 answered ?no it wasn?t?.
Plan of Correction:	All incidents will be reported to appropriate agencies within the 24-hour requirements.
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician and the report of such examination be on file at the assisted living facility. Evidence: 1. Upon request the facility did not provide a physical examination and report for resident 1 admitted 1/8/2025. 1. During an interview with staff 1, when asked if there was a physical exam or report for resident 1, staff 1 stated ?no?.
Plan of Correction:	All potential residents will have a physical examination completed within 30 days prior to admission before they can be admitted to the facility.