VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Alexandra Roberts

Inspection Date: April 22, 2022

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 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. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

Please note: a written policy should be developed regarding the use of surveillance cameras in and around the facility Reminder: All staff are required to be certified in First Aid within 60 days of employment Please consider using the DSS model form for fire drills to ensure consistent documentation of all of the requirements Please note: Standard 490.D requires that the specific residents for whom the Healthcare Oversight was provided must be identified.

Comments:

An unannounced renewal inspection was conducted on 4/13/2022. At the time of entrance five residents were in care with one staff providing care. The sample size consisted of three resident records, three staff records and one individual interview. Resident and staff records and other documentation were reviewed. Residents were observed eating breakfast and engaging in activities including music appreciation and exercise. Medication administration was reviewed. All violations were verified by Administrator during the exit interview held on 4/13/2022. 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 e-mail at lynette.storr@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on documentation review facility failed to ensure that the admission physical examination included recommendations for care including medication, diet, and therapy and a statement that specifies whether the individual is considered to be ambulatory or non-ambulatory as defined in this chapter Evidence: Resident #1's physical dated 8/27/2021 and Resident #3's physical dated 1/11/2022 indicate that the medication recommendation was attached however there was not a medication recommendation attached to the physical. Resident #3's physical dated 1/11/2022 assesses the resident as ambulatory however the most recent UAI dated 1/26/2022 assesses Resident #3 as requiring physical and mechanical assistance to transfer and walk and The Fall Risk Rating dated 1/26/2022 documents that Resident #3 is "bedbound". These assessments demonstrate that Resident #3 is non-ambulatory.
Plan of Correction:	Inspection was done with absence of the Facility administrator, the documents in question are part of resident?s old medical records produced by Cherrydale Nursing home, he was not even our resident back in 8/27/2021, we have nothing to do with his old medical records nor allowed to change or correct his old medical information and record. The physical report was done by Cherrydale Nursing home, as permitted Under code of Virginia 22VAC40-73-440, a qualified assessor in our facility determined a new AUI was needed due to Resident #3 ambulation, therefore this violation has no supportive substance, disputed and must be disregarded.
Standard #:	22VAC40-73-350-B
Description:	Based on documentation review the facility failed to ensure that prior to admission, the facility shall ascertain whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. Evidence : Residents #1, #2 and #3 do not have documentation in the record to indicate their sex offender status.
Plan of Correction:	None of our residents are part of sex offender registry and our standard sex offender forms were signed by ALL residents and presented to the inspector. We have added a print out of the search results to their file, this is NOT a care related issue.
Standard #:	22VAC40-73-440-D
Description:	Based on documentation review facility failed to ensure that the Uniform Assessment Instrument (UAI) is completed as required by 22VAC30-110. Evidence: Resident #1's UAI dated 9/15/2021 did not assess if a current psychiatric or psychological evaluation in needed.
Plan of Correction:	Resident #1 did not need psychiatric or psychological evaluation, an uncheck checkbox in his UAI has been marked and corrected. This is a paperwork related issue, has already been corrected and not care related.
Standard #:	22VAC40-73-450-C
Description:	Based on documentation review the facility failed to ensure that the comprehensive Individualized Service Plan (ISP) includes a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. Evidence: Resident #2's ISP dated1/27/2022 does not include the identified need regarding a behavioral need documented on Resident #2's Resident-Personal/Social Data Sheet. Resident #3's ISP dated 1/26/2022 does not include his use of a bedrail
Plan of Correction:	Inspection was done absence of the facility administrator, Resident #2's Resident-Personal/Social Data Sheet was part of Cherrydale Nursing home?s records, we develop our Service plan based on our qualified assessor?s UAI, and this violation has no supportive substance and under dispute. This is NOT a care related issue.
Standard #:	22VAC40-73-580-A
Description:	Based on documentation and interview facility failed to ensure the completion of subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: Facility did not provide documentation of an annual Health Inspection
Plan of Correction:	We had an annual inspection and this document was presented to the inspector, the ?county? health department failed to date stamp their original inspection. We have already been re-inspected and in full compliance. This is NOT a care related issue.
Standard #:	22VAC40-73-680-I
Description:	Based on documentation review the facility failed to document symptoms for which medication was given on the Medication Administration Record (MAR). Evidence: Resident #1's April 2022 MAR does not document the reason for which the medication is prescribed.
Plan of Correction:	Medication for resident 1 is being managed and supplied by resident?s family, our MAR system does not document medication details if meds are supplied by a 3 rd party supplier. We cannot control a 3 rd party pharmaceutical company nor is this a care related matter.
Standard #:	22VAC40-73-860-I
Description:	Based on observation facility failed to ensure that each facility shall store cleaning supplies and other hazardous materials in a locked area, except as noted in subsection J of this section. Evidence: Upon the Licensing Inspector's arrival Cascade dishwasher detergent, Dawn dishwashing liquid and Lysol were observed in an unlocked cabinet under the kitchen sink.
Plan of Correction:	We will make sure to lock on the cabinet, thank you for brining this to our attention.
Standard #:	22VAC40-73-940-A
Description:	Based on documentation and interview the facility failed to ensure that compliance with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: The facility could not provide documentation of an annual Fire Inspection.
Plan of Correction:	Our annual fire inspection has already been done for 2nd time. Fire drill records were all in compliance and presented to the inspector. This is NOT a care related matter.