VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Woodburn
3450 Gallows Road
Annandale, VA 22003
(703) 462-9998

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Sept. 21, 2021

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 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. 22VAC40-80 THE LICENSING PROCESS.

Comments:

A renewal inspection was initiated on 9/21/2021 and concluded on 9/24/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 85. The inspector emailed the administrator a list of items required for to complete the remote documentation review portion of the inspection. The inspector reviewed four resident records, four staff records, healthcare and dietary oversight reports, staff work schedule, monthly activity schedule, monthly menu, fire drill reports, annual fire and health inspection reports submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 10/6/2020 were reviewed. The inspector conducted the on-site portion of the inspection on 9/23/2021. An exit interview was conducted with the Administrator on 9/24/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-680-D
Description:	Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: According to the physician's order dated 5/21/2021, Resident #3 is to receive 2 capsules of Gabapentin at approximately 9:00 pm. The Controlled Drug Receipt/Record/Disposition form indicates that on 9/13/2021, Resident #3 received 1 capsule of Gabapentin at approximately 9:45 pm.
Plan of Correction:	There was no adverse outcome noted for this resident as a result of this occurrence. An audit of all residents' narcotic records was conducted and there was no other finding of this deficient practice. The Medication Aide who improperly administered the medication was counseled and re-educated on 10/5/2021 on the facility's Medication Management Policy which is consistent with the standards set forth by the licensing agency and the Virginia Board of Nursing. All other Medication Aides were re-educated on the Medication Management policy and process on 10/6/2021. The Medication Aides will audit residents' narcotic records daily, on each shift, as assigned and the Health Services Director will audit all residens' narcotic record on a weekly basis to monitor and ensure compliance by 10/11/2021.
Standard #:	22VAC40-90-40-B
Description:	Based upon a review of records, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. Evidence: 1.According to the staff roster, the date of hire for Staff #5 was 7/14/2021. The Criminal Record Report in the record for Staff #5 was dated 9/22/2021, more than 30 days after the 30th day of employment. 2. The facility was unable to provide a criminal history record report for the following staff: Staff #6 hired on 7/28/2021;Staff #7 hired on 8/2/2021; Staff #8 hired on 6/15/2021; Staff #9 hired on 6/15/2021; Staff #10 hired on 6/28/2021; Staff #11 hired on 7/7/2021.
Plan of Correction:	There was no adverse outcome as a result of this deficient practice. An audit of all other employees' records was conducted, and all were found to be in compliance with the standards set forth by the licensing agency. The Business Office Director was counseled and re-educated on 10/5/2021 regarding obtaining criminal history record reports for all candidates for employment prior to the actual start date of employment. The Business Office Director and Executive Director will audit records of all candidates for employment to ensure criminal history record report is obtained prior to the start date of employment, or at least, within 30 days of employment by 10/11/2021.