VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Green Acres
481 Bradley Street SW
Abingdon, VA 24210
(276) 258-5721

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Dec. 21, 2022

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 12/21/2022 Begin: 9:00am End: 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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 13 Number of staff records reviewed: 7 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to make sure that three out of 13 resident records contained all the required components on the physical examination within 30 days preceding admission to an Assisted Living Facility (ALF). EVIDENCE: 1. Resident #2 had a physical completed upon admission on 09/03/2021. Weight was left blank on the physical and it was not able to be located in the file. 2. Resident #3 had a physical completed upon admission on 09/03/2021. Weight was left blank on the physical and it was not able to be located in the file 3. Resident #6 had a physical completed upon admission on 10/08/2022. The physician did not indicated whether Resident #6 was able to self-administer medications or not.
Plan of Correction:	All physicals will be reviewed prior to admission to ensure thoroughness of physical in accordance with standards. [sic]
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to complete a Uniform Assessment Instrument (UAI) at least annually on three out of 13 residents. EVIDENCE: 1. Resident #1 was admitted to the facility on 09/23/2021. The last completed UAI was dated 09/27/2021. 2. Resident #2 was admitted to the facility on 09/03/2021. The last completed UAI was dated 12/09/2021. 3. Resident #3 was admitted to the facility on 09/03/2021. The last completed UAI was dated 05/21/2021.
Plan of Correction:	All Private UAI dates are recorded to maintain promptness and adhere to standards. [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 (ISP?s) for 1 of 13 resident files that were reviewed. EVIDENCE: 1. The ISP dated 02/16/2022 for resident #5 includes a description of needs in the areas of bathing, medication management, stairclimbing and toileting; however, it has not been updated in the following areas with regard to the aforementioned needs: a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them; when and where the services will be provided; the expected outcome and time frame for expected outcome.
Plan of Correction:	Administrator will review each ISP for accuracy before reviewing with resident and filing. [sic]
Standard #:	22VAC40-73-450-F
Description:	Based on review of resident records, the facility failed to review and update the Individualized Service Plan (ISP) for three residents out of 13 at least once every 12 months. EVIDENCE: 1. Resident #1 was admitted to the facility on 09/23/2021. The last documented ISP for Resident #1 was completed on 09/23/2021. 2. Resident #2 was admitted to the facility on 09/03/2021. The last documented ISP for Resident #2 was completed on 12/16/2021. 3. Resident #3 was admitted to the facility on 09/03/2021. The last documented ISP for Resident #3 was completed on 09/03/2021.
Plan of Correction:	Administrator shall ensure receipt of UAI from CSL and record dates to ensure promptness and completion of ISPs. [sic]
Standard #:	22VAC40-73-560-G
Description:	Based on observations made during resident record review, the facility failed to have two residents sign the required annual resident rights. EVIDENCE: 1. Residents #4, #7, #2, and #3 were admitted on 9/3/21, there was no resident rights available in the file. 2. Resident #8 was admitted on 10/19/21, there was no resident rights available in the file.
Plan of Correction:	All annual resident rights will be maintained and updated. Administrator will be maintained and updated. Administrator will ensure all signatures are obtained at resident meeting. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on document review, observation during medication cart audit and staff interview, the facility failed to implement a section of its medication management policy. EVIDENCE: 1. The facility?s medication management policy states that at the change of shifts, or when there is a change in the staff person administering medications, there will be a count of all controlled substances by the on-coming and off-gong staff person and that both staff persons must sign off on the on-coming/off going form meaning that the signatures acknowledge that the count was accurate and completed. 2. During on-site inspection on 12/21/2022, one licensing inspector noted controlled substances in the medication carts; however, interview with staff 5 revealed that medication staff are not preforming a count of the controlled substances at shift changes.
Plan of Correction:	Narcotic Count Sheet for all scheduled meds are not accounted for until medication policy is updated to reflect that all scheduled control medications are already on count themselves with count implemented within itself. [sic]
Standard #:	22VAC40-73-680-H
Description:	Based on a review of resident medication administration records (MARs), the facility failed to document all medications administered to residents, including over-the-counter medications and dietary supplements. EVIDENCE: 1. The MAR dated 12/01/2022-12/31/2022 for resident #11 does not have staff initials for the administering of Glipizide 10 MG tablet 4PM dose, and Sodium Bicarb 650 MG tablet 4pm dose, on 12/16/2022.
Plan of Correction:	Med Techs or anyone administering medications have been reminded and advised that they must initial any medication administration refused. Supervisor of each shift will review MAR at end of each med pass to ensure medications are initialed. [sic]
Standard #:	22VAC40-73-680-I
Description:	Based on medication administration record (MAR) review, the facility failed to ensure MARs contained all required components. EVIDENCE: 1. The December 2022 MAR for resident 12 did not include initials that staff administered any of the resident?s scheduled medications on 12/04/2022. 2. The December 2022 MAR for resident 13 did not include initials that staff had administered the resident?s scheduled 4:00PM Ensure on 12/01/2022 and 12/04/2022.
Plan of Correction:	Med Tech or anyone administering have been reminded/advised they must initial any medication/treatment whether administered/refused/out of facility. Med Tech Supervisor of each shift will review MAR at end of each pass to ensure medications/treatments are initialed properly. [sic]