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: March 15, 2022

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 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:

An unannounced renewal inspection was conducted on 3/15/22 (8:30 AM - 5:00 PM). At the time of entrance, 45 residents were in care. Meals, medication administration, and an activity 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 #:	22VAC40-73-1130-C
Description:	Based on documentation, the facility failed to ensure that there were enough direct care staff members, awake and on duty, during night hours. Evidence: Facility staffing schedules and census documents were reviewed during the inspection. The resident census was between 41 and 50, from 3/6/22 until 3/14/22. The staffing schedule indicates that the facility did not have at least five staff members, awake and on duty, on the following night shifts: 3/6/22 (four staff members), 3/8/22 (four staff members), 3/10/22 (four staff members), and 3/13/22 (four staff members).
Plan of Correction:	The Director of Health & Wellness has reviewed the staffing schedule and ensured five direct care staff members are scheduled on night shift when there are between 41 and 50 residents present. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding staffing. The Director of Health & Wellness or designee will review the staffing schedule daily to ensure that the appropriate number of direct care staff members are scheduled on night shift and make any adjustments necessary. The Director of Health & Wellness is responsible for implementing each step and/or monitoring any preventative measures
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: The record for Staff #1, hired 7/13/11, was reviewed during the inspection. The first aid certification in Resident #1's record expired in February 2022. No additional documentation was provided, to verify that Staff #1 had current certification in first aid.
Plan of Correction:	The Executive Director audited all direct care staff member files for current certifications in First Aid and CPR. Any direct care staff member lacking First Aid/CPR certification was notified via email and phone call. The community has arranged for a First Aid/CPR class to be offered to direct care staff. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding First Aid/CPR certifications. The Executive Director has compiled copies of all First Aid/CPR certifications by expiration date to ensure that direct care staff remain current with their certifications. The Director of Artis Way Experience will review the certifications monthly and arrange periodic First Aid/CPR classes to enable direct care staff to keep their First Aid/CPR certifications current. The Director of Artis Way Experience and the Director of Health & Wellness will ensure that all direct care staff members have current certification in First Aid/CPR.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee. Evidence: The record for Resident #3 was reviewed during the inspection. The UAI located in the resident's chart was dated 1/22/21. Facility staff reported that the resident's UAI had been updated in January 2022. That UAI, dated 1/20/22, was not signed by the administrator. Resident #5's UAI, dated 10/29/21, was not signed by the administrator. Resident #6's UAI, dated 3/10/22, was not signed by the administrator.
Plan of Correction:	The Executive Director and Director of Artis Way Experience audited all UAIs. Any UAIs lacking signature have been signed by the Executive Director. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding UAIs. The Director of Health & Wellness will ensure that each time a UAI is completed, it is timely presented to the Executive Director for review and signature. For all new residents, the UAI will be completed on or before move-in and presented to the Executive Director for review and signature. For all existing residents, the Director of Health and Wellness will track when reviews are due and ensure that the updated UAI is timely presented to the Executive Director for review and signature. UAIs will be reviewed at care conferences to ensure all required signatures are present. The Director of Health & Wellness is responsible for implementing each step and/or monitoring any preventative measures.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the resident or his legal representative. Evidence: The record for Resident #4, admitted 8/4/21, was reviewed during the inspection. Resident #4's ISP, dated 8/4/21, was not signed by the resident or his legal representative.
Plan of Correction:	The Executive Director and Director of Artis Way Experience audited all ISPs for signatures. The Director of Health & Wellness was advised of any ISPs missing signatures. The Director of Health & Wellness will contact any responsible parties whose signatures are missing to request they sign the ISP. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding ISPs. The Director of Health & Wellness will ensure that the ISP is signed by the responsible party during care conferences. If the responsible party is unable to sign at the time of the care conference, a copy of the ISP will be provided to the responsible party and signature requested. The Director of Health & Wellness or designee will document efforts to obtain the responsible party?s signature on the ISP. The Director of Artis Way Experience will conduct a random audit of 10% of the residents? ISPs monthly for three months or until substantial compliance is achieved. The Director of Health & Wellness is responsible for implementing each step and/or monitoring any preventative measures.