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: May 31, 2019 and June 3, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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.

Technical Assistance:

LI reviewed Standard 650-B-3 and emphasized completing documentation on the medication administration records.

Comments:

An unannounced monitoring study was conducted on 5/31/2019 and6/3/2019. At the time of entrance 86 residents were in care. The sample size consisted of ten resident records, five staff records, two volunteer records and four individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 6/25/2018 were reviewed. Residents were observed eating breakfast and engaging in activities including crossword puzzles. Medication administration was observed. Possible violations and risk ratings were discussed at the exit interview. The violation notice was submitted at a later date. 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 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-B
Description:	Based upon a review of resident records and interview with staff, the facility failed to ensure that the obtained written approval for placement in a special care unit shall be retained in the resident's file. Evidence: Resident #2 was admitted to the special care unit in October of 2018. There was no documentation of the approval for placement in a special care unit in the resident's record.
Plan of Correction:	1) Steps to correct the non-compliance: Resident records reviewed to ensure the approval for placement form is retained in each file. 2) Measures to prevent the non-compliance: Director or designee to audit each record of new admissions to Wellspring Village for three months to ensure compliance. 3) Person responsible for implementing and/or monitoring: Corrective action will be initiated for any variances and findings will be reported to the Executive Director. Person responsible for implementation: Executive Director or designee (9/30/19).
Standard #:	22VAC40-73-260-A
Description:	Based upon a review of records and interview with staff, the facility failed to ensure that each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years. Evidence: A review of records revealed that a direct care staff did not have a current first aid certification and that the certification had expired 12/5/2018.
Plan of Correction:	1) Steps to correct the non-compliance: Direct care associate to provide current first aid certification by 7/31/19. 2) Measures to prevent the non-compliance: Audit of direct care associate first aid certifications to be completed to ensure certifications are current. Direct care associates educated on first aid certification requirements. 3) Person responsible for implementing and/or monitoring: An audit of direct care associate first aid certifications to be completed monthly for 3 months to ensure compliance. Corrective action will be initiated for any variances and findings will be reported to the Health Services Director. Person responsible for implementation: Executive Director or designee (9/30/19).
Standard #:	22VAC40-73-640-A
Description:	Based upon a review of the Medication Administration Records (MARS), the facility failed to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: On May 14, 2019, Resident #1 did not receive the 8:00am and 4:00pm dosages of Alprazolam due to the "medication not supplied by pharmacy to administer per order." On May 31, 2019, Resident #1 did not receive Olopatidine Opth Solution 0.2%, at 8:00 am due to the medication not being available.
Plan of Correction:	1) Steps to correct the non-compliance: Alprazolam for resident #1 was administered on the next day, May 15, 2019, at the scheduled times. Eye drops for resident #1 were received on June 2, 2019 and administered as ordered. 2) Measures to prevent the non-compliance: Medication cart audit to be completed to ensure that medications ordered are available on-site. Health Services Director to provide re-education to Medication Aides on practices related to refilling medications and ensuring medications ordered are available. 3) Person responsible for implementing and/or monitoring: Medication cart audit to be completed weekly for 2 months to ensure ordered medications are available. Corrective action will be initiated for any variances and findings will be reported to the Health Services Director. Person responsible for implementation: Health Services Director or designee (8/31/19).