VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gregory's Rest Home
29255 &29271 Walker Lane
Meadowview, VA 24361
(276) 944-5350

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Dec. 10, 2019

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

Comments:

Two licensing inspectors conducted a one day unannounced mandated licensing renewal inspection at Gregory?s Rest Homes on 12/10/2019. The inspection began at 9:30 am and concluded at 12:13 pm. During this inspection required postings were checked, the noon medication pass was observed, Medication cart audits were conducted, medication administration records were reviewed, lunch was observed, buildings were observed, resident and staff interactions were observed, and a sample of resident and staff files were reviewed. There were 23 residents in care at the time of the inspection. An exit meeting was conducted with the administrator on 12/10/2019 and at that time opportunity was given to find items that were not available in files. As a result of this inspection 5 violations are being cited. Please develop a plan of correction for each of the cited violations along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (01/02/2020 ) of receipt. If you have any questions or concerns please contact your licensing inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records and physical examination reports, the facility failed to ensure all required information was included on the report for one resident in a sample of six. EVIDENCE: 1. Resident # 4 was admitted to the facility on 04/12/2019. Her physical examination report dated 04/03/2019 listed this resident is allergic to Penicillin and Latex and there was no description of reactions to these allergies was documented.
Plan of Correction:	Already corrected Dr signed off on it. Since he had filled it out-2 other places has the reaction on it-front on notebook and on social data sheet. Already corrected. [sic]
Standard #:	22VAC40-73-680-G
Description:	Based on an audit of the medication cart in House 2, the facility failed to ensure that all over-the-counter medications were labeled with the resident?s name. EVIDENCE: 1. Resident # 7 is prescribed Rexall Ice cold Analgesic Gel for her knees three times daily for knee pain. This medication was in the medication cart in House 2 and did not contain a label with Resident # 7?s name on it. Staff # 3 stated it belonged to Resident # 7, but there was not a label made for it.
Plan of Correction:	It was labeled but staff threw the bottle away and failed to create another label. already corrected. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on the review of the medication administration records (MARs), the physician?s orders, and the medication cart in House 2, the facility failed to ensure that all as needed (PRN) medications were available for the resident. EVIDENCE: 1. Resident # 9 is prescribed Ondansetron HCL 4mg tablet one tablet by mouth three times a day PRN for nausea. This medication was not available on the medication cart for Resident # 9.
Plan of Correction:	Resident meds were redirected to pharmacy because she didn't use it at all. Got a D/C order. Already corrected. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on a tour of the building, the facility failed to store all cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. In a bathroom closet the licensing inspector found a 128 ounce bottle of bleach and a 192 ounce bottle of Xtra laundry detergent. The closet had a sign on the door that read ?Cabinet to be locked at all times?.
Plan of Correction:	Staff was doing laundry and failed to lock it back-already corrected. [sic]
Standard #:	22VAC40-90-30-B
Description:	Based on review of staff records and sworn disclosures, the facility failed to ensure one staff member completed a sworn disclosure statement for employment. EVIDENCE: 1. Staff # 1 was hired on 06/24/2019. There was not a sworn disclosure statement for this employee located in her file.
Plan of Correction:	Found the form after left. Already corrected. [sic]