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: Feb. 27, 2020

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

Technical Assistance:

Documentation was discussed with the provider

Comments:

An unannounced monitoring inspection was conducted on 2/27/20. At the time of entrance, 50 residents were in care. Meals, medication administration and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and 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, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-710-C
Description:	Based on observation and documentation, the facility failed to ensure that the requirements for restraint usage were met. Evidence: A side rail was observed on the bed of Resident #4. Resident #4's record contained an order, dated 4/16/19, stating that a half bedrail may be used to prevent falls from bed. The order did not specify the condition or duration in which the restraint is to be used.
Plan of Correction:	DON and hospice were educated on the importance of the physicians order being accurate and specific for the condition and duration of the order. DON and/or designee has checked all hospice residents and any resident requiring any DME that all equipment is appropriate per physicians order. The DON and/or designee will check all hospice equipment upon delivery to ensure it meets the specifications of the physicians order. Any and all other equipment will also be checked upon delivery to ensure appropriateness to the environment. DON or designee will monitor quarterly as equipment is received to ensure appropriateness per order and environment.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. Evidence: Comet bathroom cleaner was observed in the cabinet of Resident #6. The record for Resident #6 contained an Assessment of Serious Cognitive Impairment form, dated 11/22/17, stating that the resident is unable to recognize danger or protect his own safety and welfare. Gericare ear drops, nail polish remover, and witch hazel were observed in the bathroom of Resident #9. The record for Resident #9 contained an Assessment of Serious Cognitive Impairment form, dated 8/29/19, stating that the resident is unable to recognize danger or protect her own safety and welfare.
Plan of Correction:	Staff members were educated on the importance of locking hazardous materials. Families were also educated on hazardous materials and told what is allowed and what is not allowed according to VA regulations. Maintenance/Housekeeping Director and DON will educate housekeeping and nursing staff on the importance of chemicals and the dangers of not locking hazardous material. A training will be done bi-annually. The Director of Nursing or designee will provide education to all staff on hazardous materials and the importance of locking them during orientation, bi-annually and as needed based on the needs of the community. The families will be notified upon move-in and bi-annually of the importance of making sure hazardous materials are locked at all times. DON or designee will monitor the storing and locking procedures for hazardous materials and report findings at the community staff meetings and trainings.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report, from the Department of State Police, within 30 days of hiring an employee. Evidence: The criminal history record reports, of new staff members, were reviewed during the inspection. The criminal history report for Staff #4, hired 9/12/19, was obtained on 10/26/19. The criminal history report for Staff #5, hired 3/26/19, was obtained on 6/10/19. The criminal history report for Staff #6, hired 9/12/19, was obtained on 10/26/19. The criminal history report for Staff #7, hired 9/12/19, was obtained on 10/26/19. The criminal history report for Staff #8, hired 9/22/19, was obtained on 2/17/20.
Plan of Correction:	All the staff that were identified were made sure that their criminal background report was obtained. BOM and/or designee will audit the charts to make sure no other staff are out of time frame of employment. BOM and/or designee will create a checklist of needed items prior to employment to ensure all documents are in the charts. Background check consent will be given during the time of interview and application process. BOM and/or designee will review quarterly and pull random charts to audit to make sure all staff charts are in order with the background checks.