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: June 6, 2023 and June 9, 2023

Complaint Related: Yes

Areas Reviewed:

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

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 entered the facility at 10:50 am on 6/6/2023 and exited at 3:00 pm. LI entered the facility at 8:43 am on 6/9/2023 and exited at 2:55 pm. 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 6/2/2023 regarding allegations in the area(s) of resident care and related services, and staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI observed medication administration. Additional Comments/Discussion: 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 resident care and related services. 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 #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based upon a review of records and observation, the facility failed to ensure that no medication shall be changed without a valid order from a physician or other prescriber. Evidence: On 6/9/2023 LI found the following information documented in sampled resident records: 1. The physician?s order for Resident #1?s Losartan states that the medication is to be held ?if the systolic blood pressure is less than 100.? 2. The May 2023 Medication Administration Record evidenced that on 5/6/2023 at approximately 9 am, Losartan medication was withheld ?per doctors orders? and the recorded blood pressure was 101/43. 3. The physician?s order for Resident #3?s Hydralazine documents that the medication is to be held if ?systolic blood pressure is less than 110 or diastolic blood pressure is less than 60. 4. On 6/9/2023 at approximately 10:15 am LI observed Staff #2 not administer Hydralazine to Resident #2. The documented blood pressure was 159/81 with a pulse of 40.
Plan of Correction:	Nurses educated to obtain a valid order from a prescriber for any medication change. Resident #1 and Resident #3 medication holds were assessed per community Medication Errors Policy including medication incident reports, physician and family notification and documentation in Resident #1 and #3 wellness record. Med aides educated on following prescriber?s orders when holding medication and to report to nurse. Nurse will monitor eMAR dashboard daily for any medications not given by exception to ensure this is happening per prescriber?s orders or obtain an order for any needed change. Health Services Director will monitor eMAR on a weekly basis and perform more frequent med pass observations to monitor compliance.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that Medication Administration Records include initials of direct care staff administering the medication, and any medication omissions. Evidence: On 6/9/2023, the inspector found the following information documented in sampled resident records: 1. The June 2023 Medication Administration Record (MAR) for Resident #2 evidenced no initials for the medication administration of Centrum Silver on 6/3/2023 at approximately 9am. 2. The June 2023 MAR for Resident #2 did not include documentation of any medication omission of Centrum Silver on 6/3/2023 at approximately 9am.
Plan of Correction:	Documentation omission was corrected on Resident #2?s MARS on 6/9/2023. Med aides and licensed nurses re-educated on the importance of documentation following the administration of each medication. Wellness nurse will monitor eMAR (electronic medication record) dashboard for any missed medications daily and correct timely. Health Services Director will monitor eMAR on a weekly basis to monitor compliance.