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: May 1, 2025

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 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

None

Comments:

Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 4/14/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/1/2025 from 10:00 a.m. to 11:11 a.m. 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: 29 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: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector observed resident areas including outside courtyard and exits from the facility to the courtyard. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-A
Description:	Based on record review, staff, and resident interviews, the facility failed to ensure resident safety. Evidence: 1. This facility is a safe and secure environment entirely. 2. An incident report was received from the facility by the regional licensing office stating resident 1 had used a ladder that was left in the facility courtyard to climb onto the roof requiring Emergency Medical Services (EMS) to assist resident 1 down. 3. During an interview with staff 2, when asked how resident 1 was able to climb onto the roof staff 2 stated that resident 1 used a ladder that was left inside of the courtyard to climb onto the roof. When asked to describe the incident, staff 2 stated that resident 1 had begun wandering through the facility during the night and at around 4:40 a.m. resident 1 stated they ?needed fresh air?, staff 2 then advised resident 1 to go into the courtyard and get some fresh air. 4. During an interview with staff 3 it was stated that resident 1 remained in the courtyard unsupervised for approximately 15 20 minutes until staff 2 and staff 3 saw the ladder leaning against the roof around 5:00 a.m. and subsequently resident 1 on the roof. 5. During an interview with staff 1, when asked why the ladder was in the courtyard staff 1 stated there was a roofing company at the facility 2 days prior that had left their ladder in the courtyard that the facility staff had not seen or realized was there until the incident occurred.
Plan of Correction:	Facility will be inspected daily by staff to ensure that outside grounds and inside courtyards are safe and secure.