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: March 5, 2024 and March 7, 2024

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/05/2024 9:50am to 3:20pm and 03/07/2024 9:23am to 1:14pm 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: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 9 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to maintain documentation that within the 30 days preceding admission, a person shall have a physical examination by an independent physician, including the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it, for one of the resident records reviewed. EVIDENCE: 1. Resident #2 was admitted to the facility on 01/15/2024; there was no documentation of a physical examination or TB risk assessment in the record for resident #2. 2. Staff #4 and #6 were unable to locate documentation of a physical examination or TB risk assessment for resident #2.
Plan of Correction:	Within 30 days preceding admission will have a physical examination with documenting the absence of TB. Resident #2 was a re-admission from Rehab, had a H&P from the rehab and seen the physician at facility within 2 weeks but did not have the VOSS model form in his chart. The model form will be completed by the physician and retained in his chart. The designated assistant administrator will complete the necessary admission forms assuring all forms are completed and in chart upon admission. [SIC]
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually. EVIDENCE: 1. Resident #7 was admitted to the facility on 10/16/2017; the most recent fall risk rating available on the record for resident #7 was dated 04/01/2019. 2. Staff #4 and staff #6 confirmed a more recent fall risk rating is not available.
Plan of Correction:	he fall risk rating shall be reviewed and updated under each of the following circumstances, annually, condition of the resident changes and after a fall. Annually rating shall be done in April of each year. Designated assistant administrator, med tech supervisor and administrator will complete yearly and update as needed during the year. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on Individualized Service Plans (ISPs) for four of the resident files that were reviewed. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) in the record for resident #2, dated 01/04/2024, identifies disoriented ? some spheres, some of the time (regarding place and time) and short-term memory loss. The ISP in the record for resident #2, dated 01/15/2024, does not address these needs. 2. The UAI in the record for resident #5, dated 10/03/2023, identifies shopping as an area in which resident #5 requires assistance. The ISP in the record for resident #5, dated 10/03/2023, does not address this need. 3. The UAI in the record for resident #7, dated 10/03/2023, identifies bathing (human help, physical assistance) and dressing (human help, supervision) as areas in which resident #7 requires assistance. The ISP in the record for resident #7, dated 10/07/2023, does not address these needs. 4. The UAI in the record for resident #8, dated 10/30/2023, identifies walking (mechanical help, walker) as a need in which resident #8 requires assistance. The ISP in the record for resident #8, dated 10/30/2023, does not address this need.
Plan of Correction:	All identified needs shall be addressed on ISPs. The Administrator will monitor the yearly ISPs and update as needed and address all needs annually when UAls / ISPs are due. The four ISPs in question have been updated to reflect their needs. [SIC]
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident and staff records, the facility failed to maintain written acknowledgement of annual review of rights and responsibilities of residents in assisted living facilities for three staff and six resident records reviewed. EVIDENCE: 1. Staff #1 started work on 11/01/2018; the most recent acknowledgement of annual review of resident rights and responsibilities observed in record for staff #1 was dated 01/25/2023. 2. Staff #4 started work on 05/04/2020; the most recent acknowledgement of annual review of resident rights and responsibilities observed in record for staff #4 was dated 01/25/2023. 3. Staff #5 started work on 07/09/2021; the most recent acknowledgement of annual review of resident rights and responsibilities observed in record for staff #5 was dated 01/25/2023. 4. Resident #4 was admitted to the facility on 08/25/2000; the most recent acknowledgement of annual review of resident rights and responsibilities observed in the record for resident #4 was dated 01/25/2023. 5. Resident #6 was admitted to the facility on 02/15/2013; the most recent acknowledgement of annual review of resident rights and responsibilities observed in the record for resident #6 was dated 01/25/2023. 6. Resident #7 was admitted to the facility on 10/16/2017; the most recent acknowledgement of annual review of resident rights and responsibilities observed in the record for resident #7 was dated 01/16/2020. 7. Resident #8 was admitted to the facility on 10/30/2020; the most recent acknowledgement of annual review of resident rights and responsibilities observed in the record for resident #8 was dated 01/25/2023. 8. Resident #9 was admitted to the facility on 07/15/2020; the most recent acknowledgement of annual review of resident rights and responsibilities observed in the record for resident #4 was dated 01/25/2023.
Plan of Correction:	Review of rights and responsibilities of residents in assisted living will be maintained by written acknowledgement annually. Designated assistant administrator will be responsible for yearly training. [SIC]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. EVIDENCE: 1. The licensing inspector (LI) was unable to locate the menu for the current week posted in the facility. 2. Staff #4 and #6 reported the menu is typically located by the door to the kitchen, in addition to the daily menu written on a white board in the same area. There was no menu posted by the door to the kitchen and the white board was blank.
Plan of Correction:	A weekly menu for meals and a monthly snack menu will be posted by the kitchen door each Monday morning, Kitchen staff will also post on white boards what the next meal will be. Designated assistant administrator will assure menu's are posted weekly. [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure each bedroom contains all required items. EVIDENCE: 1. There are two residents assigned to rooms #12 and #28 and only one sturdy chair and one operable bed lamp or bedside light was observed in each of the rooms. 2. There were no operable bed lamps or bedside lights observed in resident rooms #14, #18 and #26. 3. There are two residents assigned to rooms #4, #10 and #20 and only one operable bed lamp or bedside light observed in each of the rooms.
Plan of Correction:	Bedrooms shall contain the following items: bed with mattress, pillow, table, bed lamp, sturdy chair, drawer space, mirror, and window coverings. Bed side lamps and chairs have been replaced in rooms that were short. Maintenance and direct care will monitor rooms and replace missing items weekly. [SIC]
Standard #:	22VAC40-73-750-E
Description:	Based on observations made during the tour of the building, the facility failed to have sufficient bed and bath linens in good repair so that residents always have clean sheets. EVIDENCE: 1. There were no sheets observed on the bed closest to the window in resident room #11. 2. There were no sheets observed on the bed closest to the window in resident room #1. 3. There were no sheets observed on either bed in resident room #12. 4. There were no sheets observed on the bed closest to the door in resident room #10.
Plan of Correction:	The facility shall have sufficient bed and bath linens in good repair. Direct Care will make beds each morning assuring each bed has a sheet and made prior to 11 am. Supervisor will monitor for compliance. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In the sunroom, the door to the women?s restroom had several dark lines across the bottom of the door. 2. In the sunroom, there were particles of dirt and debris observed on the floor under the air conditioning unit located near the restrooms. 3. There was a large black stain observed on the wall behind the air conditioning unit located near the restrooms in the sunroom. 4. The black mats in front of the doors of the sunroom and downstairs had several lighter colored particles of dirt, debris and lint on them. 5. There were several dark spots observed on the floor near the bed closest to the window in resident room #11. 6. That was dirt and debris observed on the floor beside and under the bed closest to the door in resident room #12. 7. There were several dark spots observed on the floor of the restroom between resident rooms #3 and #4, in front of the toilet and the sink. There was also clothing left on the floor of this restroom, along with a used brief and crumpled tissue. 8. Several dark spots were observed on the floor of restroom #5, as well as a dark area/line where the flooring under the toilet meets the tile floor. 9. Particles of dirt were observed on the floor under the folding chair and tv tray in resident room #6. 10. In the sitting room, there were dark spots on the floor in front of the dark red chair, and particles of dirt were observed under the end table closest to the dining area. 11. The flooring beside and behind the toilet in restroom #18 was soiled with dark spots. 12. Several dark spots were observed on the floor in the laundry area downstairs, and in the hallway leading to resident room #26. 13. Dark spots were observed on the floor in resident room #25, in the area around the bed closest to the wall. 14. Dirt and debris was observed on the floor in the sitting area downstairs, near the outside exit, and under the water fountain in the same area. 15. There were several dark stains observed on the carpeting in resident room #28, throughout the room.
Plan of Correction:	The interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Housekeeping and Direct Care will keep areas clean by sweeping and mopping daily, they will report to Maintenance any repairs that are necessary and anything other than daily cleaning. Designated assistant administrator will monitor weekly for compliance. Administrator will provide all materials necessary to keep facility in good repair. [SIC]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. The licensing inspector (LI) observed an odor resembling urine upon walking into resident rooms #6, #11 and #19. 2. The LI observed a strong foul odor upon walking into resident room #5.
Plan of Correction:	Building shall be well-ventilated and free from foul, stale, and musty orders. Direct Care will assure trash cans that have been used to put used pull-ups in are emptied as soon as noted. Housekeeping will keep trash liners in all trash cans. Residents are encouraged to take containers out of room or let staff know that their cans need to be emptied after use. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. There were several brown spots observed on the countertop of the sink in the restroom between resident rooms #3 and #5. 2. Used toilet paper and a brown substance appearing to be feces were observed on the toilet bowl in restroom #5. 3. In restroom #8, there were dark spots on the toilet seat in the first stall, and the toilet had not been flushed as it was full of toilet paper. The rim of the toilet in the third stall had a dark spot appearing to be feces, on the front portion. 4. There were dark spots in the toilet bowl in restroom #18. 5. There were dark stains observed on the blue couch downstairs, in the middle and on the arms.
Plan of Correction:	All furnishings, fixtures and equipment including furniture, window coverings sinks, toilets, bathtubs and showers shall be kept clean and in good repair and condition .. Housekeeping and Direct Care will keep areas clean by sweeping and mopping daily, they will report to Maintenance any repairs that are necessary and anything other than daily cleaning. Designated assistant administrator will monitor weekly for compliance. Administrator will provide all materials necessary to keep facility in good repair. [SIC]
Standard #:	22VAC40-80-120-E-2
Description:	Based on observations made during a tour of the building, the facility failed to post required documents related to the terms of the license on the premises, including the findings of the most recent inspection of the facility. EVIDENCE: 1. The findings of the renewal inspection that occurred on 03/08/2023 were posted in the facility, however, the most recent inspection occurred on 02/15/2024. 2. Findings of the most recent inspection were not posted on the premises.
Plan of Correction:	The findings of the most recent inspection of the facility shall be posted outside the nurses station. When inspections findings are issued to facility, administrator will post that day a copy of the findings. [SIC]
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The date of hire for staff #3 was 08/13/2023; the criminal history record report was requested by the facility on 11/06/2023.
Plan of Correction:	Criminal history record shall be obtained prior to the 30th day of employment for each employee. The designated assistant administrator will complete the criminal history request and administrator will send to VA State Police within the first week of employment. [SIC]