VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Great Falls Assisted Living
1121 Reston Avenue
Herndon, VA 20170
(703) 421-0690

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: May 7, 2024 and May 8, 2024

Complaint Related: No

Areas Reviewed:

Inspection Type: Renewal Unannounced Mandated Areas of Standards Reviewed: REVIEWED AREAS OF STANDARDS 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 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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: 05/07/2024 05/08/2024 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: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 19 Number of interviews conducted with residents: 2 and (2-Collateral) Number of interviews conducted with staff: 3 Observations by licensing inspector: Toured the facility, observed medication administration, and checked the medication cart for prescribed medications. LI also observed residents participating in activity programs and eating lunch. 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 ,Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.kabiri@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-D
Description:	Based on record review, the facility failed to ensure that the annual training for medication aides shall include continuing education as required by the Virginia Board of Nursing. Evidence: 1. Five of the six registered medication aids, did not complete a four-hour refresher training course. 2. Staff 12, 13, 15, 16, 17?s record had medication refresher training dated 3/30/23.
Plan of Correction:	1. Steps to correct the non-compliance with the standards. - The Director of Health and Wellness arranged for a medication refresher training on 6/13/24 which was completed by six medication aides. All other medication aides are likewise arranging to take the refresher course. 2. Measures to prevent the non-compliance of standard from occurring again. - The Director of Health and Wellness will ensure all medication aides provide annual proof of medication refresher training. A copy will be maintained in their Associate file and the license tracking binder which will be audited by the Director of Health and Wellness to ensure sustained compliance. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness
Standard #:	22VAC40-73-220-B
Description:	Based on record review, the facility failed to ensure that private duty personnel are qualified for the types of direct care or companion services they are responsible for providing to residents and maintain documentation of the qualifications. Evidence: 1. Staff #18?s record did not contain a copy of certification for direct care credentials. 2. Interview with Staff #4 confirmed the credentials were not in Staff #18?s record.
Plan of Correction:	1. Steps to correct the non-compliance with the standards. - The Community obtained a copy of the private duty personnel?s certificate of completion of nurse aide education and placed in the private duty personnel?s credentialing file. 2. Measures to prevent the non-compliance of standard from occurring again. - The Director of Health and Wellness will ensure any private duty personnel have evidence of certification of direct care credentials on file at the Community. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness
Standard #:	22VAC40-73-350-A
Description:	Based on the record review and staff interview, the facility failed to ensure that the assisted living facility registered with the Department of State Police to receive notice of the registration or registration of any sex offender within the same or contiguous zip code area in which the facility is located. Evidence: 1. Staff 1 provided a copy of the Department of State Police registration dated May 2, 2024. 2. Staff 1 stated they were unaware that the facility had not registered. Staff 1 registered the facility when it was determined it had not been done.
Plan of Correction:	1. Steps to correct the non-compliance with the standards. -The Community registered with the Department of State Police on May 2, 2024 following an internal audit and was in compliance prior to the licensing inspection. 2. Measures to prevent the non-compliance of standard from occurring again. -The Community is registered through the Executive Director and will ensure that it updates the registered email address as needed to remain in compliance. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Executive Director