VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gray Ridge Village LLC
155 Ridgefield Rd
Marion, VA 24354
(276) 521-0784

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: March 24, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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

Comments:

The licensing inspector for Gray Ridge Village conducted a one day non mandated monitoring inspection on 03/24/2022, the inspection began at 10:15am and concluded at 12:26pm. The focus of this inspection was to look at previous violations and look at the compliance with the intensive plan of correction. Resident files were reviewed, residents were interviewed and the building and grounds were observed. An exit meeting was held with the administrator of the facility on the date of the inspection, 03/24/2022. At that time the opportunity was given to find items that were not available in files. As a result of the inspection, 10 violations are being cited. Please develop a plan of correction for each violation cited along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (04/28/2022) of receipt. If you have any questions please feel free to contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on observations made during the inspection of the physical plant, the facility failed to maintain an effective pest control program. EVIDENCE: 1. Room #21, in the bottom drawer of the nightstand, there was mouse droppings found during the 3/24/22 inspection. 2. Room #28, mice droppings were observed in the top of the night stand and on the floor behind the nightstand. 3. Room #32 had mouse droppings and a large amount of mouse droppings in the top drawer of the night stand. 4. Residents #2, #3, and #4 told LI on the date of the 03/24/2022 inspection that they had seen mice in the dining room of the facility. 5. Room #24, the resident reports that he has seen mice in his room and there were mouse droppings beside of this bed when the LI was there on the 03/24/2022 inspection. 6. Residents #5, #6, and #7 told the LI on the 03/24/2022 inspection that they had seen mice in their room recently. 7. Resident #8 stated she had seen mice on A hall of the facility. 8. Room #36, the resident stated she saw two small mice in the kitchen area a few nights ago. 9. There was evidence of a mouse problem as there were sticky traps and live mouse traps sitting out in numerous (at least 20) different places within the facility.
Plan of Correction:	The facility continues to use Halls pest control services and maintains the pest control program. Halls pest control services is still doing monthly treatments and will be notified for inspections as needed to help with treatment of the mice issue. Staff will go and check all rooms for mouse droppings and clean all rooms appropriately by 05/06/2022. 1.Halls Pest Control will continue services at the facility and will increase to bi-monthly visits. 2.Maintenance Staff will ensure sticky traps are checked daily and replaced as needed. Will continue to monitor for signs of mice in the facility. The kitchen area will have added traps. 3.Resident rooms #5, #6, #7 will have sticky traps added to their rooms. 4. Records will be kept on file at the facility with invoices for pest control and any new treatments/suggestions from pest control. Daily monitoring will be documented. 5. Rooms 21, 28, 24, 32 will continue to be monitored for the dropping and for other evidence of mice in the rooms. 6. Will continue to deep clean all room on a weekly schedule. Make sure trash is removed from all resident rooms daily along with keeping areas free of clutter. 7.Continue to remind and encourage residents to keep all snacks in airtight containers. 8.Residents will continue to be reminded to assist in keeping their rooms clean, not leaving food lying around. 9. Direct care will be assisted rooms and areas to check daily with reports to the management team. 10.Management teams will have rooms assigned to check weekly and do a written report on the findings and things that were corrected. Administrator to monitor, Licensee to monitor [sic]
Standard #:	22VAC40-73-450-F
Description:	Based on observations made during the tour of the physical plant and the review of resident records, the facility failed to update the Individualized Service Plan (ISP) for significant change of resident's condition. EVIDENCE: 1. In Room #31 there was no wardrobe, no bed side table, no clothes in the room, no pillow, blanket, or sheet on the bed. 2. According to Staff #1 this was due to the resident's mental health diagnosis, and that he has requested these items not be in his room. This was not documented on this resident's IPS.
Plan of Correction:	ISP was reported to have previously been faxed to licensing. I have included the updated ISP for room #31 with this plan of correction Administrator and RCA will continue to monitor. Licensee will continue to monitored. [sic]
Standard #:	22VAC40-73-660-B
Description:	Based on observations made during the physical plant tour, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medications. The medications shall be stored so that they are not accessible to other residents. EVIDENCE: 1. There was a container of Vicks Vapor Rub on the night stand in Room #39, other residents easily had access to this item. 2. Room #20 had a bed side table and on top of the table was a container of Dermasil. This item was easily accessible to other residents. 3. Room #36 had hemorrhoid ointment in the bottom drawer of the bed side table. The UAI for this resident dated 7-16-2021 rated the resident dependent in medication administration and must be monitored by a lay person. 4. Room #33, in the top drawer of the night stand there was a box of Top Care Cough and Cold HBP, 16 tablets found. This resident is not rated independent in medication administration according to a statement from Staff #1.
Plan of Correction:	The facility will monitor the use of self-administered medications and ensure that residents who are uncapable of administering their own medications will not have medications in their room. Residents who do are able to have medications in their room will be instructed on keeping medications put away and out of reach of other residents for safety. 1.Daily checks of all rooms to ensure no medications are left on nightstands and/or dressers. 2.Remove all medication from resident rooms who do not have UAI that states they can self-administer. 3. Daily checks by RMAs to ensure that no medications are left in the room with residents who do not have order to self-administer and/or UAI contradicts self-administration. Administer to monitor, RCD to monitor. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the tour of the physical plant, the facility failed to administer medications in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Room #14 was found to have a bed side table with a nebulizer on top of the table, this belonged to the resident that had the bed against the wall. The mouthpiece to the nebulizer was dirty and crusted with a yellow substance. 2. Room #24 was found to have a nebulizer on the bed side table. This nebulizer was found to have an appearance of a brown dirt substance visible in the mouth piece. Staff #1 states the mouth pieces of the nebulizers were replaced in February, and the insurance will only pay to replace them one time per month.
Plan of Correction:	All resident nebulizers will be cleaned weekly and air dried. All tubing/mask/mouth pieces and/or spaces for use with the nebulizers will be changed monthly RCD will monitor, Administrator will monitor. [sic]
Standard #:	22VAC40-73-750-C
Description:	Based on observations made during the inspection of the physical plant and an interview with one resident, the facility failed to maintain written specification that a resident does not wish to have an item in his room. EVIDENCE: 1. The LI observed Resident #1 to not have a bottom sheet on his bed. Resident #15 stated he did not want a bottom sheet on his bed. When the LI asked the administrator if there was written specifications between the facility and the resident, she reported there was a document signed by both the resident and the facility and it was sent to the LI via email, but the document could not be located on the date of the inspection today, 03/24/2022.
Plan of Correction:	There is a document signed by both the new administrator and the resident from the facility that states the resident refuses and does not want any sheets on the bed. The 2 violations sited will be faxed with a plan of correction to the licensee. 1.ISP will be updated on all residents who refuse or do not want bed sheets. 2 Written specifications will be placed on the chart of any resident that refuses any equipment, furniture, bedding, or other things in their room. RCA and Administrator will continue to monitor and notify licensee of changes in ISPs with residents [sic]
Standard #:	22VAC40-73-820-A
Description:	Based on observations made during the tour of the physical plant, the facility failed to ensure that smoking by residents, staff, volunteers, and visitors shall only be done in areas designated by the facility and approved by the State Fire Marshal or local fire official. EVIDNECE: 1. Room #25 had a strong smell of cigarette smoke and had been smoking in his room. 2. Room #33 had a strong smell of smoke and smoke was lingering in the air when the LI walked in. The resident stated his vaping machine may have went off while in his pocket.
Plan of Correction:	Residents know that they are not allowed to smoke in their rooms. We have continuously spoken with them about this. 1.Continue to remind residents that they are not allowed to smoke in their rooms or bathrooms and only in designated smoking area. RCA to monitor, Administrator to monitor. [sic]
Standard #:	22VAC40-73-860-D
Description:	Based on observations made during the inspection of the physical plant, the facility failed to ensure any operable window shall be effectively screened. EVIDENCE: 1. In resident rooms #31, #33, #34, and 39 there were two windows to the outside and only one had a screen. 2. This violation was cited for these residents during a previous inspection on 01/04/22.
Plan of Correction:	As of 04/28/2022 All resident rooms have screens and/or air conditioners, expect resident room #37 and it will be corrected by 05/03/2022. 1.All rooms will continue to be monitored for screens and sealed areas around the air conditioners. 2. Room 37 will have air conditioner and screen in Maintenance and Administrator will monitor Administrator will update licensee Licensee will monitor. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on the observation made during the inspection of the physical plant, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept free of rubbish. EVIDENCE: 1. On the porch of the courtyard area the LI found two Styrofoam cups, one empty pack of cigarettes and four to five cigarette butts lying on the ground as well as evidence that residents had been spitting what appeared to be phlegm on the porch floor. 2. The door leading to the outside courtyard located in the common sitting area was is disrepair, the door did not close effectively. The middle hinge was only attached by one screw, the top hinge was attached to the door and the bottom hinge was not attached at all to the door frame. 3. Room #11 has a dresser, the drawer on the left falls out when opening and the closet door was off of the track. 4. Room #25 had a dirty bathroom. The floor around the toilet was found to be black all around with dirt and had not appeared to have been cleaned. There was a dark brown dried liquid that had dripped down the wall.
Plan of Correction:	The closet door in room 11 was fixed back on track by staff while the licensee was still here for inspection. 1.All porches will be swept and cleaned per shift by direct care and/or housekeeping staff. 2.The door leading to the outside courtyard has been ordered by the owner of the facility but shipping states 8-12 weeks for delivery. While waiting to be replaced, the hinges will be fixed with new screws. 3.All furniture in the facility will be in good working order and if it cannot be fixed, it will be replaced. 4.The facility will ensure that the building interior and exterior will be clean and free from trash and rubbish. 5. Bathrooms will be deeply cleaned weekly +and painted if necessary. 6.All closet doors will be kept on tracks or replaced as needed. Maintenance, RCD, Administrator will continue to monitor. Licensee will monitor [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the physical plant, the facility failed to have all buildings well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. At 10:09 am during the 03/24/2022 inspection, Room #28 had a very strong urine odor in her room.
Plan of Correction:	Room 28 has an inconvenient resident that at times refuses to allow staff to change her due to her mental diagnosis. 1.Will continue to encourage residents to allow direct care to change her undergarments when she has episodes of incontinence. 2.Will continue to check resident room every 2 hours for unpleasant odors and need for assistance with cleaning self and room. RCA and administrator to monitor. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the inspection of the physical plant, 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. EVIDNECE: 1. The bathroom door in room #25 had what appeared to be a dark, dried liquid stain running down the front of the door. 2. Room #20 was observed to have a bed with the sheet hanging off the side of the bed. The sheet was observed to have a large yellow stain. 3. Room #14 has a top drawer of the nightstand which was found to be unsteady and unsecure falling off the track into the floor when opened. 4. Room #9 has a nightstand and in the bottom drawer of the night stand there was dirt and loose tobacco found. 5. Room #28, the second drawer in the chest of drawers where the TV sits was broken and unsecure off the track and falling out.5 6. All of the above violations were cited during the previous inspection dated 01/04/2022
Plan of Correction:	1. All furniture, fixture and equipment will be repaired or replaced. 2. Sheets that are stained will be discarded and new sheets will be obtained. All residents will have clean sheets that are free from tears and/or stains. 3. Nightstands, Maintenance will continue to monitor, Administrator will continue to monitor dressers, and other furniture in rooms will be in good working condition and cleaned. These will all be replaced and/or fixed. 4. Room #25 bathroom has been cleaned but is stained. The door will be painted. Licensee will monitor [sic]