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: Feb. 10, 2022 and Feb. 18, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced focused monitoring inspection regarding self-reported incidents began on 2/10/2022 and ended on 2/18/2022. Three resident records were reviewed. LI walked the physical plant including observation of the door to the servery room located on the secured care unit and the elevator located in the servery room on the secured care unit. Interview with administrator was conducted and other documents were reviewed. Violation notice issued, risk ratings reviewed and exit interview 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 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 #:	22VAC40-73-460-D
Description:	Based upon a review of records and interview with administration, the facility failed to provide supervision of resident schedules, care, and activities. Resident #1, who has a serious cognitive impairment, was unsupervised and whereabouts were unknown to staff from approximately 6:41pm to approximately 6:50pm on 2/4/2022. Evidence: 1. The record for Resident #1 verifies that they reside in the facility?s secure care unit that is one level and located on the first floor of the facility. The Uniform Assessment Instrument (UAI) for Resident #1 dated 11/16/2021, documents that the resident has a behavior pattern of wandering weekly or more and that the resident is "disoriented to all spheres all of the time." The Individualized Service Plan (ISP) for Resident #1, dated 12/3/2021, documents the need for staff to monitor the resident's dementia and that resident "may have exit seeking behavior and staff may need to make sure to know where she is at all times. The ISP indicates that Resident #1 diagnosis include: Alzheimer?s disease and behavioral and psychological symptoms of dementia. 2. Based on interview on 2/10/2022, the administrator verified that she reviewed camera footage from 2/4/2022 and determined that at approximately 6:41 pm on 2/4/2022, Resident #1 was seen on camera standing in the foyer of the secured care unit. The written statement provided by the concierge present at the time of the incident on 2/4/2022 states that at approximate 6:40pm on 2/4/2022, the concierge observed Resident #1 ?trying to open the door from Wellsprings Village (name of the secured care unit) to the lobby. Soon after she walked away back thru the threshold in Wellspring foyer. I called one of the lines in Wellspring, no answer after a few rings. Then I got a call that I needed to answer.? 3. According to the work schedule there were five staff working on the secured care unit on 2/4/2022 during the 2pm to 10pm shift. Written statements of the staff working on the secured care unit at the time of the incident indicates that Staff #1 was the last staff person to observe Resident #1 in the secured care unit. The written statement from Staff #1 states that Staff #1 observed Resident #1 ?about 6:40pm on 2/4/2022 when I was walking with another resident to put that resident to bed. Resident #1 was walking to activity room area.? The activity area is located across from the dining room area of the secured unit. 4. Based on interview with the administrator on 2/10/2022, at approximately 6:50 pm on 2/4/2022, a resident assistant, who was on the third floor pushed the button to summon the elevator and when the elevator doors opened, Resident #1 was located in the elevator. The third floor of the facility is for assisted living residents and is not part of the secured care unit. The written statement of Staff #2 states ?I was about taking the elevator at the third floor and I saw a resident coming out of the elevator cart #1 so I called the nurse on duty to be a witness and she came.? Staff #2df and Staff #3 (who was the nurse on duty) both took Resident #1 back to the secured care unit. 5. Staff #3 was the nurse on duty and in her written statement indicates that at approximately 6:50pm on 2/4/2022, she was called by the RMA on duty to go to the elevator on the 3rd floor. Staff #3 wrote in her statement ?When I arrived, (Staff #2) was in the elevator with (Resident #1) holding on to the elevator door so it does not close.? Staff #3 later documents in her written statement that Staff #2 and Staff #3 took Resident #1 back to the secured care unit and ?investigated staff on how resident got off the village. Nobody was able to tell. Resident was assessed stable and no distress noted.? Due to extensive information additional evidence is located on a separate form.
Plan of Correction:	Each associate who works in the Wellspring Village will be re-educated on resident safety and elopement risks. Care plans of all residents were reviewed, and a list was made of those who are exit-seeking; associates were reminded that these residents are particularly at risk for elopement. Concierge Associates were re-educated that if they see a resident on the cameras in the foyer of Wellspring Village, they are to notify staff within Wellspring Village or direct an associate to the neighborhood immediately. They were also oriented to the list of exit-seeking residents. All education to be completed by March 4, 2022. Wellspring Village Director will review the list of exit-seeking residents at monthly health and wellness meetings and reinforce resident safety. The Business Office Director will reinforce resident safety at monthly concierge meetings. Wellspring Village Director, Business Office Director, and Executive Director are responsible for implementation and monitoring of plan of correction.
Standard #:	22VAC40-73-860-D
Description:	Based upon an interview with the administrator, the facility failed to ensure that all doors shall open and close readily and effectively. Evidence: During an interview with the administrator on 2/10/2022, it was revealed that the door to the servery area that is for employees only and located on the secured care unit, failed to close properly on 2/4/2022 at approximately 6:43 pm. Resident #1 was able to open the door and enter the servery area unsupervised.
Plan of Correction:	Associates were reoriented to the posted sign with instructions to push firmly and to ensure door latches. Security contractor inspected door on 2/6/2022 and adjusted mechanism. Additional repairs to the door frame were completed on 2/8/2022. Security contractor came back on 2/10/2022 and confirmed door was working properly. All repairs were completed on 2/8/2022. Exit doors in Wellspring Village will be rounded on daily by the maintenance director or Manager on Duty to ensure they are working properly. Staff will immediately report if a door is not closing properly, and this will be escalated to the security contractor immediately. The maintenance director will be responsible for implementing and monitoring the plan of correction.