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: June 29, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Documentation was discussed with the provider

Comments:

A non-mandated monitoring inspection was initiated on 6/29/21 and concluded on 7/14/21. A self-reported incident was received by the department regarding allegations in the area of: Resident Care and Related Services. The licensing inspector conducted an on-site observation of the facility on 6/29/21. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-325-C
Description:	Based on record review and interview, the facility failed to document an analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce risk of subsequent falls. Evidence: Resident #1 was admitted to the facility on 4/2/21. On 4/4/21, Resident #1 fell in the facility?s secure outdoor area and he was taken to the hospital for evaluation. Resident notes state that Resident #1 was diagnosed with abrasions and facial bruising. Resident #1 was noted to have three stiches on his chin, when he returned to the facility. No information was included in the resident record, to document the interventions that were initiated to prevent or reduce the risk of subsequent falls after Resident #1?s fall on 4/4/21. On 6/14/21, Resident #1 was found face down in the facility?s secure outdoor area. Resident #1 was noted to be bleeding from the chin, he had a deep cut/laceration, and a possible tooth injury.
Plan of Correction:	Interventions to prevent or reduce risk of subsequent falls are documented for Resident #1 related to his fall on 6/14/21. Director of Health and Wellness and/or designee will audit records for all residents who have had a fall in the past 30 days to ensure interventions to prevent or reduce risk of subsequent falls are documented. The Vice President of Health and Wellness re-educated the Director of Health and Wellness regarding fall risk assessments and appropriate interventions. The Director of Health and Wellness and/or designee will provide education to all Coordinators of Health and Wellness regarding the requirement to document interventions to prevent or reduce risk of subsequent falls. Director of Health and Wellness and/or designee will review resident records for the next 60 days or until the community deems substantial compliance for all new move ins and all residents who have a fall and ensure interventions to prevent or reduce risk of subsequent falls are documented.