VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greendale Home
18180 Rich Valley Road
Abingdon, VA 24210
(276) 628-8595

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Feb. 18, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Please ensure the resident rights information page located in resident files are updated with the correct name of the current licensing administrator and phone number.

Comments:

Two licensing inspectors conducted a one day mandated renewal inspection at Greendale Home on 02/18/2020. The inspection started at 9:15 am and concluded at 12:53 pm. A sample of resident and staff files were reviewed. Required postings were checked. The noon medication pass was observed and medication cart audits were conducted. Lunch and snacks were observed being served. Activities were observed along with staff interacting with residents throughout the inspection. An exit meeting was held with the administrator on 02/18/2020 and at that time opportunity was given to find items not available during the inspection. As a result of this inspection 9 violations are being cited. Please develop a plan of correction for each cited violation along with a date of correction and return a signed copy back to the licensing office within 10 days (02/29/2020) of receipt. If you have any questions or concerns, please contact your inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records and subsequent tuberculosis (TB) evaluations and reports, the facility failed to ensure three staff members were evaluated annually in a sample of four. EVIDENCE: 1. A subsequent tuberculosis evaluation was not completed for the following staff members: Staff # 2 was hired by the facility on 07/25/2018. The most recent TB evaluation for staff # 2 was dated 07/21/2018. Staff #3 was hired by the facility on 11/01/2018. The most recent TB evaluation for staff # 3 was dated 04/12/2018. Staff # 4 was hired by the facility on 11/01/2018. The most recent TB evaluation for staff # 4 was dated 04/12/2018.
Plan of Correction:	Health information required by these standards shall be maintained at the facility and be included in the staff record for each person. A subsequent tuberculosis evaluation has been performed on all outdated evaluations and filed in staff charts. Office staff will monitor the annual dates for re-evaluation of each staff member and keep records current. Administrator will monitor staff charts annually to assure all required records are current. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records and physical examination reports, the facility failed to ensure the physical examination report included all of the required information for one resident in a sample of eight. EVIDENCE: 1. Resident # 4 was admitted to the facility on 02/05/2019. The Physical Examination Report for this resident dated 01/23/2019 did not include a statement that specifies whether this resident is or is not capable of self-administering medications.
Plan of Correction:	A statement that specifies whether the individual is or is not capable of self-administering medication has been added to the physical used for new admissions. Resident # 4's physician has amended her physical to address this. DON will monitor all new admissions and assure this has been done on their physical prior to admission. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on observations and documentation review made during the Medication Administration Record (MAR) and physician?s order review, the facility failed to ensure no medication, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. Resident # 12 was discharged from the hospital on 10/29/2019. He was prescribed Magnesium Citrate one bottle daily as needed for constipation. 2. Resident # 12 saw his primary care physician on 11/08/2019, the physician prescribed Magnesium Citrate, drink one bottle up to twice per week as needed for constipation. 3. There was no discontinue order for the Magnesium Citrate one bottle daily as needed for constipation found in the resident?s file, and Staff # 3 verified the facility had not obtained a discontinue order for the Magnesium Citrate one bottle daily as needed.
Plan of Correction:	No Medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued, by the facility without a valid order from a physician or other prescriber. DON will monitor all orders from a hospital admission that has returned to the facility to assure no orders are overlapping, and get clarification from the physician on orders, physician discontinuing any orders that are no longer active. Medication aides notifying DON of any conflicting orders and get clarification if necessary. [sic]
Standard #:	22VAC40-73-700-1
Description:	Based on review of resident records and oxygen therapy orders, the facility failed to ensure the physician?s orders included the oxygen source such as compressed gas or concentrators for one resident in care. EVIDENCE: 1. Resident # 10 receives oxygen therapy, two liters at night, and the physician?s orders for this resident does not included the source of the oxygen.
Plan of Correction:	The facility will have a valid physician's order that includes the following: The oxygen source, such as compressed gas or concentrators. Residents with oxygen orders have been updated to state the type. DON will monitor new orders to assure the order specifies the source to be used. [sic]
Standard #:	22VAC40-73-710-C
Description:	Based on observations made during the morning tour of the building, physician?s orders, and resident interviews, the facility failed to have a physician?s written order for the use restraints. EVIDENCE: 1. Resident # 13 was found to have half rails on one side of her bed. She was not able to tell staff or the licensing inspector what these bed rails are used for. There was no physician?s order in her file specifying the condition, circumstance and duration under which this restraint is to be used. 2. Resident # 13's bed is located against the wall on one side with the bed rails being on the other side. 3. Staff # 2 stated resident # 13's family must have brought them in and placed them on her bed without staff being aware.
Plan of Correction:	If a restraint is used it will be imposed in accordance with a physician's written order that specifies the condition, circumstance, and duration under which the restraint is to be used: and not to be ordered in a standing, blanket, or "as needed" bases. Whenever physical restraints are used all conditions will be met. Side rail was removed from bed, family has been educated on the uses of restratints and what is considered to be a restraint. Family is supportive of a restraint not to be used for resident at this time. Direct care will report to supervisor if a restraint is being used without orders, supervisor will obtain orders if needed and have standard conditions met. [sic]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure the hot water taps that are available to residents are maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. EVIDENCE: 1. The hot water in the sink used for hand washing in the women's common bathroom located in the sun room measured 133.4 degrees Fahrenheit.
Plan of Correction:	Hot water at taps available to residents shall be maintained within a range of 105 F and 120 F. Due to the location of the hot water heater (on the other side of bathroom wall) staff will monitor the water temperature periodically during their shift to assure the temperature is within the range. Water temperature does go down with water running. Maintenance will monitor hot water heater thermostat and keep on lowest setting. Housekeeping and Direct Care will monitor during their shift and report to maintenance if setting needs adjusting. [sic]
Standard #:	22VAC40-73-870-C
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure adequate provisions for the collection of garbage was made. EVIDENCE: 1. The side patio area located downstairs had a large white trash bag was found opened and approximately half full of garbage and untied.
Plan of Correction:	Adequate provisions for the collection and legal disposal of garbage, ashes, and waster material shall be made. Housekeeping and maintenance will monitor that all garbage is taken out to the waste bins as it is collected. Direct care will notify housekeeping of any garbage that needs to be disposed of. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure that all equipment including sinks, toilets, bathtubs, and showers shall be kept clean and in good repair and condition. EVIDENCE: 1. The women?s bathroom located in the sun room, the first bathroom on the right in the downstairs area, and the bathroom near room # 29 downstairs, all had a black ring around the base of the toilet where the toilet meets the tile that appeared to be built up particles of dirt, dust, and waste matter.
Plan of Correction:	All furnishings, fixtures, and equipment shall be kept clean and in good repair and condition. All bathroom floors are being striped, cleaned and new silicone around bottom of commode where it meets the tile. Housekeeping will monitor/clean these areas daily to prevent the buildup. Administrator will monitor areas that may need more attention and notify housekeeping or maintenance of findings. [sic]
Standard #:	22VAC40-73-980-H
Description:	Based on observations and staff interview, the facility failed to ensure the availability of a 96 hour supply of drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. EVIDENCE 1. The licensing inspector located 43 gallons of water in the facility. The recommendation from the Federal Department of Homeland Security at ready.gov is one gallon of water per person per day. The facility had an average census and staff of 60, therefore, there should be 120 gallons of water on site. Staff # 2 stated the facility was not in compliance with this standard.
Plan of Correction:	At least 48 hours supply of drinking water will be on hand at the facility. Maintenance and office staff will monitor and rotate supply. A total of 120 gallons are at facility and will be on hand at all times. [sic]