VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Great Falls
10200 Colvin Run Road
Great falls, VA 22066
(703) 759-2513

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: June 14, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES

Technical Assistance:

Incident Reporting

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/14/2024: 4:15 PM to 5:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/11/2024 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-720-A
Description:	Based on facility record review, the facility failed to ensure that Do Not Resuscitate (DNR) orders were included in the individualized service plan. (ISP) Evidence: 1. Resident 1 has a signed DNR order dated 05/09/2024 located in her business chart. 2. Resident 1?s ISP, dated 05/13/2024, lists her code status as ?Full Code? and is stored in her medical chart. 3. Resident 1?s ISP did not include the written order for the DNR. 4. This DNR order was reviewed with Staff 1 and 3 and confirmed to be missing from the ISP.
Plan of Correction:	Steps to correct the non-compliance: Resident 1?s ISP was updated to list her code status as Do Not Resuscitate (DNR) on 6/15/24. Measures to prevent the non-compliance: Wellspring Village Director audited all Wellspring Village ISPs on 6/15/24 to ensure code status on ISP matched code status in business record. Wellspring Village Director or designee will audit Wellspring Village ISP?s monthly for 3 months to ensure code status is consistent between ISP and business record. The Plan of Correction and 3 month audits to be reviewed at monthly QAPI/Safety Committee meetings for compliance/next steps.