VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Dulles Corner
13700 Magna Way
Herndon, VA 20171
(571) 786-5800

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Aug. 12, 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 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2- (1) GENERAL PROVISIONS 63.2- (18) 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

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/12/2024, 9:00 am-2:40pm and 08/13/2024, 9:30 am-3:00 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 16 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities, Breakfast and 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 #:	22VAC40-73-40-A
Description:	Based on staff interviews and a review of records, the facility failed to be in compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws, with other relevant regulations; and with the facility?s own policies and procedures. Evidence: 1. In an interview with the LI (Licensing Inspector) Resident 11 stated that the call bells are answered too slowly. 2. In an interview with the LI, Resident 12 stated that the staff takes a long time to answer the call bells. 3. Staff 1 stated during the interview on 08/13/2024, with the LI (Licensing Inspector) that the facility?s policy for call bell answer time is between 7-10 minutes. 4.The facility?s call bell logs confirm the following times: A. On 8/2/2024, 10:47 am, Resident 13?s call bell was responded to in 1 hr and 45 minutes. B. On 8/2/2024, 7:57 pm, Resident 14?s call bell was responded to in 45 minutes. C. On 8/4/2024, 6:48 pm, Resident 16?s call bell was responded to in 48 minutes. D. On 8/5/2024, 1:50 pm, Resident 12?s call bell was responded to 39 minutes. E. On 8/11/2024, 7:48 pm, Resident 15?s call bell was responded to in 59 minutes.
Plan of Correction:	Steps to correct the non-compliance: The community cannot retroactively correct the call bell response times noted on 8/2,8/4,8/5,and 8/11/2024. Measures to prevent the non-complinace: A printout of the response times will be run daily by HSD or designee andreviewed daily at morning stand up meeting with all directors. All calls answered in greater than 10 minutes will be investigated and reson for delay documente. Health and Wellness associates in-serviced on the call bell response procedure and expectations to answer calls in a timley manner on 8/12/2024. POC to be reviewed at monthly QAPI/Safety Committee meetings by HSD or designee for compliance. Person responsible for Implementing and monitoring,
Standard #:	22VAC40-73-220-B
Description:	Based on the Resident record review and a staff interview, the facility failed to ensure that direct care or companion services are reflected on the Resident?s ISP. (Individualized Service Plan. Evidence: 1.Resident 7?s ISP does not indicate the specific duties and frequency of those duties companion personnel will provide.
Plan of Correction:	Steps to correct the non-compliance: Resident 7's ISP updated to indicate the specific duties and frequency of the duties, companion personnel will provide for resident 7 on 8/12/2024. Measures to prevent the non-compliance: Currect Residents with direct care or companion services ISPs are being audited, if necessary to indicate the specific duties and frequency of the duties companion personnel will provide by 8/12/2024. Health and Wellness nurses in-services on the requirements of the ISp to include the specific duties and frequency of the duties companion personnel will provide for resident on 8/30/2024. HSD or designee will audit residents with direct careor companion care services ISPS once per 4 weeks to measure the continued compliance. Person responsible for Implementing and Monitoring: POC to be reviewed at monthly QAPI/Safety meetings by HSD or dsignee
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to obtain the resident?s signature on the acknowledgment of Orientation form upon admission to the facility for new residents including emergency response procedures, mealtimes, and use of the call system. Evidence: 1.Resident 2 (admitted on 05/25/2024) did not have an orientation form signed by the resident. 2.Resident 5 (admitted on 12/20/2023) did not have an orientation form signed by the residents.
Plan of Correction:	Steps to correct Non-Compliance: Resident 2 and 5 orientation acknowledgement form for receiving orientation including emergency response procedures, mealtimes, and use of call bell system were signed on 8/15/2024. Measures to prevent the non-compliance: Current resident's orientation (handbook acknowledgement form) will be reviewed and signed by residents and as appropriate, thier legal representatives will be reviewed, signed, dated by the residents and their RP with a completion date of 10/30/2024. All sales associates and BOD in-serviced on apprpriate signatures of the resident and as appropriate as their RP for the resident orientation (handbook) acknowledgement form on 8/15/2024. Person responsible for implementing/Monitoring: BOD or designee will audit resident's business files for approperiate signature on the oreintation (handbook) acknowledgement for for 4 weeks to measure continued compliance. Any forms not meeting compliance will be flagged and corrected immediately by BOD or designee.POC to be reviewed at monthly QAPI/Safety meetings for continued compliance.
Standard #:	22VAC40-73-460-A
Description:	Based on record review and interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. LI observed Resident 12 during the inspection on 08/13/2024, during a medication pass in their wheelchair. 2. Resident 12?s wheelchair arm on the right side, had exposed foam over the metal. The black leather covering is torn and worn exposing the foam underneath. 3. Resident 12 stated in an interview that the armrest with the exposed foam and metal, gets caught at the dining table and bothers his arm. 4. Photos taken as evidence.
Plan of Correction:	Steps to Correct the non-Compliance: The resident/family is responsible to purchase and maintain residents's DME. The community is responsible for notifying the resident/ need for the maintenance and repair. The resident/family is responsible for the approval and payment for repair and replacement of parts or device. Community discussed needs for repair/replacement and approval for payment with esident 12/family on 8/15/2024. Resident 12's wheel chair was replaced on 8/26/2024. Measures to prevent the non-compliance: All Health and Wellness associates inserviced to notify community Directors if any resident's DME needs maintenance or repair. Community HSD inservicd on notification of resident/family and to get for DME epair and replacement on 8/12/2024 POC to be reviewed Person responsible for Implementation or Monitoring: POC to. be reviewed at monthly QAPI/Safety committee meeting by the HSD or designee for compliance.
Standard #:	22VAC40-73-660-A-7
Description:	Based on observation, the facility failed to ensure that single-use and dedicated medical supplies are appropriately labeled and stored. Evidence: 1.During the inspection and medication cart audit on 08/12/2024, at 12:17 pm, the LI (Licensing Inspector) observed 1 box of BD Nano 2nd gen pen needles without a prescription label or other identifiable information. 2.Photos taken as evidence.
Plan of Correction:	Steps to Correct Non-Compliance: 1 box of BD Nano 2nd gen pen needles were removed from med cart and labeled with the appropriate label on the day of survey 8/12/2024. Measures to Prevent the non-compliance All med carts were audited for appropriatelabeling and storage of single use and dedicated medical supplies on 8/12/2024. All health and wellness associates administering medications ( med techs/LPN)re-trained regarding appropriate labeling and storage of single-use and dedicated medical supplies on 8/30/2024. Person Responsible for Implementation and/or Monitoring: HSD or designee will audit med carts for appropriate labeling and storage of single use and dedicated medical supplies once per week for 4 weeks to measure continued compliance. POC to be reviewed at monthly QAPI/Safety meetings for compliance.
Standard #:	22VAC40-73-700-1
Description:	Based on the review of Resident records and Physicians' orders, the facility failed to ensure when oxygen therapy is provided the physician's order includes the oxygen source. Evidence: 1.Resident 3?s physician?s order, dated 03/21/2024, for oxygen does not state the source of oxygen being compressed gas or a concentrator.
Plan of Correction:	Steps to correct the non-compliance: Resident 3's physician order for oxygenupdated to include the source of oxygen on 8/15/2024. Measures to prevent the non-complinace: Currecnt residents with physician orders for oxygen were audited and corrected if no source of oxygen is specified in the physician order on 8/15/2024. Health and wellness nurses in-serviced on required source for any resident physician Oxygen orders on 8/30/2024. HSD or designee will audit resident physicianOxygen orders for source once per week for 4 weeks to measure the continued compliance. Person responsible for Implementing and Monitoring: POC to. be reviewed at monthly QAPI/Safety committee meeting by the HSD or designee for compliance.