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: May 19, 2022 , June 2, 2022 and June 30, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI was at the facility on 5/19/2022 from 9:39 am to 2:30pm, on 6/2/2022 from 10:14 am to 4:00pm and on 6/30/2022 from 10:10 am until 1:15pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/16/2022 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 8 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Buildings and Grounds: 930-B A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-930-B
Complaint related:	No
Description:	Based upon interviews, the facility failed to ensure that in a building licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1.According to interview with Staff #1 on 6/2/2022, the facility began experiencing issues with call bell alerts ?around 5/2/2022.? Staff #1 indicated that direct care staff would receive an alert that a call pendant had been pushed but the direct care staff could not determine which room the call pendant alert was coming from. 2. Staff #2 was interviewed on 6/2/2022 and asked how long there has been an issue with the signals to the staff phones not indicating which room the signal was coming from. Staff #2 indicated that staff have made several complaints the last two months that when a call bell pendant was pushed, their phones would not alert them as to which room the call was coming from. 3. Staff #4 was interviewed on 6/9/2022. Staff #4 was asked if he experienced any issues with the phones not indicating which room a call bell alert was coming from. According to Staff #4, he did have experience with receiving a call bell alert on his phone but not being able to determine where (which room) the call bell alert was coming from. Staff #4 stated ?the facility tried several times to fix the issues with the phone.? 4. Staff #5 was interviewed on 6/2/2022. Staff #5 reported that ?there had been issues with staff not getting alerts that a resident?s call bell had been pushed.? According to Staff #5 the issue with the phones not providing information as to where the call bell alert was coming from started two weeks ago. Staff #5 stated ?staff had to figure out where the call was coming from because it was not showing up on their phone.?
Plan of Correction:	1. Steps to Correct Noncompliance ? Pager System was installed by Fusion Factors on Monday, May 23, 2022. The Fusion Factor Representative in-serviced our Wellspring, Assisted Living, and Maintenance directors on the proper usage of the Pagers (how to read, delete and clear pagers). The individual pagers were programmed and distributed to all caregivers. Once the pendant is activated by the Resident, the signal is sent to the Associates Pager indicating Resident Name/Room Number. Once the Associate responds to the page, the Associate will clear the call from their assigned pager. 2. Education/Monitoring ? The Assistant Living, Wellspring, and Maintenance Directors were educated on proper use of the Pagers by a Fusion Factor Representative (how to read, delete, and clear pagers). The Directors then provided inservice for Resident Assistants, Nurses, MedTechs, Vibrant Living Assistants, and Concierges on the proper use of the new pager system. The Assistant Living Director or designee monitored response times daily for 1 week and weekly for 3 months (10 call/response times) 3. Measures to Prevent the Noncompliance ? Daily monitoring of the Pager call system by the Assisted Living Director or designee. Coordination of a new Wi-fi and E-call system is in the planning stages for Brightview Great Falls Community. Wi-fi will be upgraded first followed by the E-call system (issuing Apple devices) to replace the pagers/scout phones at which time the Pagers will become our backup system.