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 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Technical Assistance:

Fall Risk Assessments

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: 9:05 AM to 4:15 PM 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: 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, Activities, Medication Pass, Kitchen. Additional Comments/Discussion: N/A 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-350-A
Description:	Based on staff interview, the facility failed to ensure registration with the Department of State Police to receive notice of the registration or reregistration of any sex offender within the same or a contiguous zip code area in which the facility is located. Evidence: 1. A copy of current registration or a recent email to confirm registration was requested to Staff 1. 2. Staff 1 confirmed they were not registered to receive these alerts.
Plan of Correction:	Steps to correct the non-compliance: Business office director registered with Virginia State Police Sex Offender Registry to be notified when any sex offender moves within the same or contiguous zip code of the facility location. Measures to prevent non-compliance: Registration confirmed 6/21/2024.
Standard #:	22VAC40-73-560-E
Description:	Based on direct observation, the facility failed to ensure that all resident records retained at the facility were kept in a locked area. Evidence: 1. The nurses? station on the terrace level was observed to be unlocked. 2. In the nurse?s station, Resident 4 and Resident 7 had posted medical information. 3. In the memory care unit, Staff 4?s office was unlocked. 4. A resident?s uniform assessment instrument (UAI) was face up on the desk. 5. Staff 1 locked the door of the office upon request.
Plan of Correction:	560-E Based on direct observation, the facility failed to ensure that all resident records retained at the facility were kept in a locked area. Evidence: 1. The nurses? station on the terrace level was observed to be unlocked. 2. In the nurse?s station, Resident 4 and Resident 7 had posted medical information. 3. In the memory care unit, Staff 4?s office was unlocked. 4. A resident?s uniform assessment instrument (UAI) was face up on the desk. 5. Staff 1 locked the door of the office upon request. Steps to correct the non-compliance: The terrace level nurses? station and staff #4?s office were locked on day of survey after notification to Executive Director of non-compliance. Measures to prevent the non-compliance: The Medication Technician assigned to the terrace level nurses? station and staff 4 were counseled regarding ensuring the doors are always locked when they leave the room. Executive Director or Designee will audit staff 4?s office door for compliance once per week for 4 weeks to measure continued compliance. POC to be reviewed at monthly QAPI meetings for compliance,
Standard #:	22VAC40-73-620-B
Description:	Based on facility document review, the facility failed to ensure the special diet oversight included a certification that the requirements of this subsection were met. Evidence: 1. The special diet oversight was completed on 03/21/2024. 2. The special diet oversight did not contain a statement certifying that the requirements of this subsection were met.
Plan of Correction:	Steps to correct non-compliance: Contractor providing Dietician oversight has agreed to adjust their form to include a statement certifying that the requirements of 620-B.3 subsection were met at onsite visit. Measures to prevent non-compliance: Executive Director or designee will perform monthly audit for 3 months to ensure that Dietician oversight report forms include the certifying statement as required. POC and audits to be reviewed at monthly QAPI meetings for compliance/next steps.
Standard #:	22VAC40-73-640-D
Description:	Based on the direct observation and staff interview, the facility failed to ensure that a pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two (2) years old is readily accessible for staff who administer medications. Evidence: 1. A drug reference book dated 2020 was observed in the terrace level nurse?s station. 2. An updated copy was requested to Staff 1 and Staff 3. 3. Staff 1 confirmed they did not have a copy that is no more than (2) years old available.
Plan of Correction:	Steps to correct the non-compliance: 2024 drug reference books were ordered immediately following survey. Measures to prevent non-compliance: Executive Director or designee received 2024 drug reference books and placed on medication carts on 7/2/2024. POC to be reviewed at monthly QAPI meetings for compliance.
Standard #:	22VAC40-73-660-A-1
Description:	Based on direct observation, the facility failed to ensure that medication administered by the facility was stored in a locked medicine cabinet, container, compartment. Evidence: 1. The nurses? station on the terrace level was observed to be unlocked. 2. In the nurses? station, the fridge was unlocked. 3. Inside of the fridge was medication for Resident 8.
Plan of Correction:	Steps to correct the non-compliance: The terrace level nurses? station and fridge were locked on day of survey after notification to Executive Director of non-compliance. Measures to prevent the non-compliance: The Medication Technician assigned to the terrace level nurses? station was counseled regarding ensuring the fridge and door are always locked when she leaves the room. Health Services Director or designee will audit nurses? station doors and refrigerators once per week for 4 weeks to measure continued compliance. POC to be reviewed at monthly QAPI meetings for compliance.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure that when oxygen therapy is provided, the facility has a valid physician or other prescriber?s order that includes the oxygen source such as compressed gas or concentrators. Evidence: 1. Resident 1 has physician orders started on 10/04/2023 for oxygen therapy. 2. The order states ?Oxygen 2L/M via Nasal Cannula PRN shortness of breath.? 3. The order does not include the oxygen source.
Plan of Correction:	Steps to correct the non-compliance: Health Services Director has contacted physicians providing oxygen orders for the community to change orders to include the oxygen source. Measures to prevent non-compliance: Health Services Director or designee will audit oxygen orders once per month for 3 months to verify orders include oxygen source. POC to be reviewed at monthly QAPI meetings for compliance.