VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Green Valley Commons Assisted Living
549 Valley Mill Road
Winchester, VA 22602
(571) 359-1499

Current Inspector: Jill James (540) 418-2631

Inspection Date: June 3, 2024

Complaint Related: No

Areas Reviewed:

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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

The Licensing Inspector discussed 22VAC40-73-440 re-taking UAI training in order to stay updated on current criteria for assessing and completing the form. The Licensing Inspector discussed 22VAC40-73-80. Management of resident funds to ensure funds are tracked separately, deposits are made promptly and adequate oversight for checks and balances.

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/3/2024 8:00am-6:00pm and 6/4/2024 8:15am-2:25pm. 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: 8 Number of staff records reviewed: 8 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector observed building operations, meal pass, med pass, and kitchen operations. Comments/Discussion: n/a 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review and interview, the facility disclosure statement was not the current Department of Social Services (VDSS) form. EVIDENCE: 1. Chart review for Resident 1, Resident 2, Resident 3, identified a facility generated disclosure statement that did not include the departments website address, with a note that additional information about the facility may be obtained from the website. 2. Staff 9 acknowledged that the disclosure statement used by the facility did not comply with standards.
Plan of Correction:	Disclosure was update 6-15-24 including the increased staff. We added the department website address with a note that additional information may be obtained from the website. We will review annually update as needed. Written copy will be given to the resident and representative. Copy will be retained in resident chart. Correction will be made for using VDSS form Aug 1 2024 will have to inspector for review.
Standard #:	22VAC40-73-200-E
Description:	Based on record review and staff interview, the facility failed to ensure a written plan was developed and implemented for supervising 1 of 3 staff who needed to complete required training within 60 days of hire. EVIDENCE: 1. Staff 3 (date of hire 5/6/2024) had not completed DCA, nurse?s aide, personal care aide, or other required training. 2. Staff 9 acknowledged that a plan did not exist.
Plan of Correction:	Facility will have written plan developed and implemented for supervising direct care aides in training. Supervisor will monitor them on the floor Until the direct care aide has completed training. Written plan will be completed 7-23-24 for supervising direct care aides.
Standard #:	22VAC40-73-280-A
Description:	Based on record review, observation, and interviews, the facility failed to ensure there was sufficient staff to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. EVIDENCE: 1. During the building tour on 6/3/2024, the 9:00 am devotion was not observed being conducted. The 10:00 am coloring activity was not observed being conducted. At these times the two staff, a direct care aide and medication technician, were observed providing housekeeping, resident care, and medication pass. 2. Resident 10 stated that activities are not typically done. Resident also stated that bathrooms were not regularly cleaned and that two staff is not enough. 3. Staff 8 stated that devotions were not completed due to staff assisting with resident care. 4. Disclosure statement states there will be 3 staff per shift, 2 direct care and 1 housekeeping. The observed schedule and staff working on 6/3/2024 and 6/4/2024 were 2 staff consisting of 1 medication technician and 1 direct care aide.
Plan of Correction:	Facility has increased staffing on dayshift. One medication aide with two direct care aides. The aide will be on duty everyday from 8-4 .Increased staff will be helping with care and activities. This will ensure our resident?s physical, mental, and psychosocial well being of each resident will be met. Administrator will be monitoring to insure we are in compliance with VDSS. Disclosures were updated June, 15, 2024 and reviewed with licensing. Corrected June 7th 2024 we added three staff to day shift extra person for eight hour shift.
Standard #:	22VAC40-73-310-D
Description:	Based on record review and staff interview, the facility failed to provide written assurance that the facility had the appropriate license to meet the care needs at the time of admission and that copies were signed by the resident?s or legal representatives were kept in the resident charts. EVIDENCE: 1. Written assurance was not in Resident 1 (date of admission 2/14/2023), Resident 2 (date of admission 4/24/2024), and Resident 3 (date of admission 6/22/2023) charts. 2. Staff 9 acknowledged that the written assurance was not completed and placed in resident charts.
Plan of Correction:	The facility added the written assurance in the resident agreement .Administrator will review with resident and legal representative. We will have the agreement signed and give them a copy. Administrator and assigned staff will assume responsibility for future compliance is met under VDSS standard. Corrected June 7th assurance was added to our resident agreement will be ongoing.
Standard #:	22VAC40-73-350-A
Description:	Based on staff interview, the facility failed to ensure registration with Virginia State Police (VSP) in order to receive notification of sex offenders who reside within the same zip code. EVIDENCE: 1. The LI requested documentation of registration with the VSP and was not provided that documentation. 2. Staff 9 acknowledged that the facility was not registered with the VSP to receive the sex offender notification.
Plan of Correction:	Administrator registered the facility on the Virginia State sex offender registry on 6-25-24. All sex offender notifications will be available to residents and their representatives at all time.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure 2 of 6 resident individualized service plan's (ISP) were updated after a significant change. EVIDENCE: 1.Bed rails were observed for Resident 1. 2. Resident 1 ISP (dated 3/24/24) has a handwritten note adding hospice services on 5/20/24. Staff 9 stated rails were used for positioning. 3. The ISP for Resident 1 was not updated by the facility to include the use of bed rails as an assistive device. 2. didn?t delete this space to retain comment stream. 4. Bed rails were observed on the bed of Resident 5. 5. Resident 5 ISP (dated 4/29/24) did not include bed rails as an assistive device. 6. Staff 9 stated the bed rails were used as an assistive device.
Plan of Correction:	Administrator updated Care Plan on all residents whom use half bedrails as an assistive devise. Care plans will be monitored and updated with any changes in resident needs. Correction was completed on 7-8-24 for all residents in need of assistive devices.
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and staff interview, the facility failed to ensure the health care oversight (HCO) was completed at least quarterly or more often based on the resident?s ability and need. EVIDENCE: 1. Healthcare Oversights were conducted on 10/19/2023, 1/25/24, 3/3/24, and 6/7/2024. 2. Staff 9 acknowledged that HCO was not conducted quarterly.
Plan of Correction:	The Administrator will ensure and monitor the health care oversight will be done quarterly. Oversight nurse will do at least quarterly or more often based on resident needs. Oversight was conducted on 6-7-24. All resident will be included annually in the health care oversight
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interview, the facility failed to ensure the drug reference book was more than two years old. EVIDENCE: 1. Upon request, two drug reference books were presented, both were dated 2017. 2. Staff 9 acknowledged that the drug reference books were outdated. 3. Photo taken.
Plan of Correction:	Facility Purchased drug reference book 6-7-24. Materials for staff that administer medication have now on their cart. Administrator will order new material every two years.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the exterior of the building was maintained and in good repair. EVIDENCE: 1.The railing along a walkway that led to the courtyard, overlooked the driveway approximately 12 feet below. This railing wobbled excessively. 2. The LI discussed with Staff 9 the railing and Staff 9 immediately requested maintenance begin to secure the railing. 3. The LI observed maintenance personnel the same day adding additional bracing to the railing.
Plan of Correction:	Maintenance has repaired the railing 6-4-24. Administrator and maintenance will continue to monitor interior and exterior for compliance with VDSS standard.
Standard #:	22VAC40-73-930-D
Description:	Based on record review the facility failed to ensure staff rounds were consistently documented for residents who were unable to use the call system. EVIDENCE: 1. The round log for Resident 4 did not include staff initials from 7:00pm, 6/2/2024, through 6:00am the next morning, 6/3/2024. 2. LI interviewed Staff 8 who stated that rounds are to be completed every hour due to resident inability to use the call bell system. 3. Staff 9 confirmed that the round log was not initialed during the previously stated timeframe.
Plan of Correction:	Staff will monitor resident q1hr and document. Administrator will retrain staff in policies and procedures for monitoring residents with inability to ring call bell. The inability will be noted on the care plan to insure needs are met. Staff meeting is scheduled 7-25-24. Administrator will be reviewing with all staff. The medication aide in charge will monitor Daily for compliance with VDSS. I have communicated already with all supervisors and the staff person that was on duty. 6-5-24
Standard #:	22VAC40-73-940-A
Description:	Based on record review and interview, the facility failed to ensure the annual fire inspection was completed. EVIDENCE: 1. Record of the last fire inspection was completed on 4/6/2023.
Plan of Correction:	Fire inspection was completed on 6-21-24 no violations. Administrator will be in compliance with the statewide fire prevention code. Requiring at least an annual inspection by the appropriate fire official and retention of report. Administrator/Designee will call 30 days prior to inform them due next month.
Standard #:	22VAC40-73-950-F
Description:	Based on staff interview, the facility failed to ensure a review of the emergency preparedness plan was completed and documented annually or more often as needed. EVIDENCE: 1. LI requested the emergency prepardness plan. 2. Staff 9 acknowledged that the emergency preparedness plan was not reviewed annually for needed updates.
Plan of Correction:	The Administrator completed the updated Emergency preparedness plan on 6-15-24. All staff, residents, and volunteers will review the plan annually and document. The Administrator will do orientation with all new hires. The orientation and review shall cover responsibilities for alerting emergency personnel and sounding alarms. Implementing evacuation shelter is in place and relocation to Green Valley Manor. Using, maintaining, and operating emergency equipment. Accessing emergency medical information, equipment, and medication for residents. Locating and shutting off utilities, Utilizing community support including but not limited to, 911, Red Cross, and Fredrick County response team. The facility will notify family and legal representatives and report the disaster or emergency to VDSS by the next day after disaster or emergency is stabilized.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and staff interview, the facility failed to ensure that fire drills were completed for each shift in a quarter. EVIDENCE: 1. Fire drills in February, March, April, and May of 2023 were all conducted on the morning shift (7:00am-7:00pm). 2. Staff 9 confirmed that the fire drills were not conducted on any other shift.
Plan of Correction:	Fire drills will be done monthly. Administrator will monitor that all shifts will be completed quarterly. Staff did completed a drill June,22,2024 at 3:30am with overnight shift . Facility will be in compliance with VDSS.
Standard #:	22VAC40-73-980-H
Description:	Based on observation, the facility failed to ensure availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time. EVIDENCE: 1. LI observed 19 gallons of emergency water supply in the kitchen. Current census is 29. 2. Staff 9 stated the facility did not have a contract for emergency water. 3. Photo evidence.
Plan of Correction:	On sight we have 48 hours worth of food and water. Our kitchen manager will oversee the emergency food. She will monitor dates and amounts. We have a contract with Schenck Foods effective 7-1-224. Contract was faxed to licensing.
Standard #:	22VAC40-73-990-B
Description:	Based on record review and staff interview, the facility failed to ensure resident emergencies were reviewed with all staff at least every six months and documented with staff signature and date of review. EVIDENCE: 1. Resident emergency drills on 1/1/2024, 4/5/2024, and 4/24/2024 did not include all staff. 2. Staff 9 acknowledged that emergency plan documentation did not include all staff.
Plan of Correction:	Administrator will ensure that each staff currently on duty each shift monthly. Will participate in an exercise in which the procedures for resident?s emergencies are practices. We scheduled a staff meeting 7-25-24 to review and document the drill. The Administrator and Designee to insure that moving forward this training is performed at least once every six months with all staff as required by VDSS standard.
Standard #:	63.2-1720-E
Description:	Based on record review and staff interview, the facility failed to ensure the criminal history record reports (CHRRs) for new staff were completed within 30 days of hire. EVIDENCE: 1. Staff 8 (date of hire on 9/12/2023) CHRR was completed 10/27/2023. 2. Staff 7 (date of hire 9/21/2023) CHRR completed 10/27/2023. 3. Staff 9 acknowledged these documents were obtained late.
Plan of Correction:	Administrator will ensure the criminal record is obtained on or prior to the 30th day of employment for each employee. They will be completed and mailed out same day of hire. All future criminal checks will be in compliance with the standard of VDSS. Correction will be effective now 6-5-24