VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greenbrier Assisted Living
8204 Madrillon Estates Drive
Vienna, VA 22182
(571) 253-1000

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: Oct. 27, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

Licensing Inspector (LI) conducted unannounced complaint investigation on 10/27/2021 regarding resident medication, staff qualifications and billing practices. LI reviewed resident and staff records and medication administration records. Spoke with Administrator/Owner and the staff on duty. The complaint is deemed valid as a preponderance of evidence gathered during the investigation supported the allegations regarding resident medication and staff qualifications. Exit interview conducted on 11/9/2021 and the violation notice regarding the standards deemed valid was left for correction. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via email at lynette.storr@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-A
Complaint related:	No
Description:	Facility failed to ensure that a record shall be established for each staff person. Evidence: Staff #2 who was working at the facility when the Licensing Inspector arrived did not have a staff record established.
Plan of Correction:	Secured electronic copy of the staff record was available and provided, we will make sure to retain a paper copy inside the facility. This is not a care related matter.
Standard #:	22VAC40-73-290-A
Complaint related:	Yes
Description:	Based on documentation review, observation and interview the facility failed to ensure that a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time is maintained. Evidence: Upon the Licensing Inspector's arrival on 10/27/2021 the posted work schedule did not correctly indicate the staff member that was currently working in the facility.
Plan of Correction:	We had one staff called out due to being sick, an unscheduled employee was covering the shift, we re-printed the shift schedule. This is not a care related matter.
Standard #:	22VAC40-73-290-B
Complaint related:	Yes
Description:	Based on observation and interview the facility failed to ensure that the current on-site person in charge is posted. Evidence: Upon the Licensing Inspector's arrival on 10/27/2021 the current on-site person in charge was not posted.
Plan of Correction:	We had one staff called out due to being sick, an unscheduled employee was covering the shift, we re-printed the shift schedule. This is not a care related matter.
Standard #:	22VAC40-73-440-B
Complaint related:	Yes
Description:	Based on document review and interview the facility failed to ensure that for private pay individuals, the UAI shall be completed by an assisted living facility staff person who has successfully completed state-approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments. Evidence: Resident #1's most recent UAI was completed by Staff #1. There is no documentation to indicate that Staff #1 completed the state-approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments.
Plan of Correction:	Secured electronic copy of the state approved UAI certification has already been provided, facility to ensure to retain a paper copy inside the facility. This is not a care related matter.
Standard #:	22VAC40-73-440-F
Complaint related:	Yes
Description:	Based on documentation review and interview the facility failed to ensure that the UAI shall be completed within 90 days prior to admission to the assisted living facility. Evidence: Resident #1's most recent UAI was incomplete. It did not indicate the assistance required in each of the ADL categories.
Plan of Correction:	The UAI was partially complete due resident #1 was new and was still under additional evaluation. We will make sure to comply with this requirement. This is not a care related matter.
Standard #:	22VAC40-73-450-B
Complaint related:	Yes
Description:	Based on documentation review and interview the facility failed to ensure that the person who develops the ISP has successfully completed the department-approved individualized service plan (ISP) training. Evidence: Resident #1's most recent ISP was developed by Staff #1. There is no documentation to indicate that Staff #1 has completed the approved ISP training.
Plan of Correction:	Secured electronic copy of the state approved ISP certification has already been provided, facility to ensure to retain a paper copy inside the facility. This is not a care related matter.
Standard #:	22VAC40-73-560-H
Complaint related:	Yes
Description:	Facility failed to ensure that for at least the first year after the resident leaves the facility, the record shall be retained at the facility. Evidence: Based on documentation review and interview Resident #2 who was discharged from the facility did not have a resident record at the facility. The Owner indicated that the record had been moved offsite.
Plan of Correction:	As informed, we are a technologically advanced company, electronic copy of the discharged resident was available and has already been provided, facility to ensure to retain a paper copy inside the facility. This is not a care related matter.
Standard #:	22VAC40-73-660-B
Complaint related:	No
Description:	Facility failed to ensure that the medication and any dietary supplements shall be stored so that they are not accessible to other residents. Evidence: Based on observation and interview Ipratropium Bromide Nasal Spray and Moisture Eye Drops were found on a cabinet in the living room and were not being stored in a manner consistent with current standards of practice.
Plan of Correction:	This was an over the counter eye drop (no risk). The staff in charge of the shift was immediately terminated, the facility to ensure staff are informed of this requirement. This is not a care related matter.
Standard #:	22VAC40-73-680-G
Complaint related:	Yes
Description:	Facility failed to ensure that over-the-counter medication shall be labeled with the resident's name, or in a pharmacy-issued container, until administered. Evidence: Based on observation and interview Ipratropium Bromide Nasal Solution and Moisture Eye Drops were not labelled with the resident's name.
Plan of Correction:	This was an over the counter eye drop (no risk). The staff in charge of the shift was immediately terminated, the facility to ensure staff are informed of this requirement. This is not a care related matter.
Standard #:	22VAC40-73-925-B
Complaint related:	No
Description:	Facility failed to ensure that common face/hand washing sinks shall have paper towels or an air dryer and liquid soap for hand washing. Evidence: Upon the Licensing Inspector's arrival there were no paper towels or an air dryer available in the common bathroom.
Plan of Correction:	We had ran out of paper towel in one toilet, we will make sure to put additional paper towel.