VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Great Falls Assisted Living
1121 Reston Avenue
Herndon, VA 20170
(703) 421-0690

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: May 7, 2019 and May 17, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Unannounced complaint inspections were conducted on 5/7/19 and 5/17/2019, in response to a complaint that was received by the licensing office on 4/30/19 regarding resident care and related services. Resident record observed, interviews were conducted and facility documentation was reviewed. The allegation regarding standard 550.C was not valid, as the evidence gathered did not support the allegation. The allegation regarding standard 460.H was determined to be valid, as a preponderance of evidence gathered during the investigation supported the allegation. An exit meeting was held. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: Bathing - at least twice a week, but more often if needed or desired. Evidence: Resident #1's shower record, from March - April 2019, was reviewed during the inspection. Resident #1's UAI, dated 12/1/18, states that the resident needs physical assistance for bathing. According to the shower record, Resident #1 received six showers over the course of seven weeks (3/10/19 - 4/27/19). No documentation of shower refusals was provided, during the inspection.
Plan of Correction:	Resident #1 had a shower record that was being used but staff were not putting the refusals or bed baths. Staff were retrained and told any attempt and/or refusal has to be documented to make sure we are in compliance. An audit of all staff shower records will be completed to identify any other missing records. All staff will be retrained during staff meeting to make sure they are aware that refusals must also be documented. The DON and/or designee will check shower records on rounds and make sure staff are following procedures. The DON and/or designee will do monthly audits on all shower records to ensure all necessary information is documented.