VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Green Valley Manor
1011 Pennsylvania Avenue
Winchester, VA 22601
(540) 450-5642

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: May 24, 2023

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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

1.Job description for administrator ? update with change to residential only. 2.Review/clarify DAP plans as some indicate a potential level of care higher than facility is licensed for. 3.Whenever suicidal ideation, past or present, is noted in a resident record it needs to be included on the service plan ? staff have had mental health first aid training. 4.Discussed staff not taking breaks all at the same time despite the building being residential only.

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: 5/24/23 The Acknowledgement of Inspection form was signed and left at the facility for the 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. Refer violation notice. Issues noted primarily with condition of bathrooms. Building itself was clean and odor free. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 3 Observations by licensing inspector: All the resident I spoke with both inside and outside the building voiced no major concerns. The door alarm is now working to alert staff when someone is entering or exiting the building. Several residents were excited about the upgrades to the outside back area. The facility changed from assisted living to residential only during this licensing year. They continue to upgrade the second building to begin a transition activity program which based on conversations residents would greatly appreciate. The med cart was clean and organized and meds were administered as prescribed. Postings were as required. Outside inspections were current as were related required drills. Additional Comments/Discussion: Fire ? 8/25/22 Health ? 2/7/23 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with three applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee had the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-390-A
Description:	Based on a review of six resident records along with a random review of agreements and Discharge Assistance Planning agreements, specific charges for services, accommodations, and care to be needed were not indicated consistently on either. Many were also lacking signatures.
Plan of Correction:	All agreements, both facility and discharge assistance planning, will be reviewed and updated to include signatures and necessary information as cited. The administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-860-G
Description:	Water temperatures in the back portion of the building did not meet the standard of being maintained within a range of 105 to 120 degrees.
Plan of Correction:	Maintenance immediately addressed and temperatures corrected to be within required range. Staff to monitor temperatures at least monthly. Administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-870-E
Description:	The exhaust fans in the bathrooms were covered with thick dust. The paint is also peeling from the walls in the back bathrooms in several places within the room. The showers are stained.
Plan of Correction:	Maintenance addressed cleaning the exhaust fans. There are plans to redo the bathrooms. Housekeeping staff will notify maintenance in the future regarding necessary cleaning. Administrator to be responsible for ensuring correct and future compliance.