Inspection Reports for Brightview Great Falls Assisted Living & Memory Care
VA, 22066
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Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 3
Aug 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-07-13 regarding allegations related to staffing and supervision, and resident accommodations and related provisions.
Findings
The investigation supported the complaint of non-compliance with multiple standards, including failure to report major incidents within 24 hours, failure to ensure staff were considerate and respectful of residents' rights and dignity, and failure to maintain sufficient staffing levels on the Safe, Secure unit. Violations were issued and plans of correction were required.
Complaint Details
The complaint investigation substantiated violations related to staffing and supervision, and resident accommodations. Evidence included interviews, video footage of mistreatment, and staffing schedule reviews. Staff 4 was terminated following the investigation of mistreatment allegations. Staffing shortages were documented for multiple dates in June and early July 2025.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that any major incident negatively affecting residents was reported to the licensing office within 24 hours. |
| Facility failed to ensure all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or have disabilities. |
| Facility failed to ensure sufficient staff numbers to provide services to maintain the physical, mental, and psychosocial well-being of each resident. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Safe, Secure unit census: 22
Dates staffing plan not met: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 | Named in mistreatment allegation and terminated following investigation | |
| Staff 1 | Interviewed and confirmed notification of mistreatment allegation and staffing plan details | |
| Staff 3 | Interviewed and acknowledged failure to report incident and staffing plan non-compliance | |
| Staff 2 | Interviewed and observed video footage with licensing inspector |
Inspection Report
Monitoring
Deficiencies: 3
Jun 13, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-04-08 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation supported the self-report of non-compliance with multiple standards, resulting in violations issued related to documentation for private duty personnel, failure to ensure resident health and safety, and failure to secure immediate medical attention after a serious incident. Plans of correction were provided for each violation.
Deficiencies (3)
| Description |
|---|
| Facility failed to maintain appropriate documentation when private duty personnel from licensed home care organizations provide direct care or companion services before services are initiated. |
| Facility failed to assume general responsibility for the health, safety, and well-being of the residents, including an incident of abuse involving a private duty aide. |
| Facility failed to ensure that medical attention from a licensed health care professional was secured immediately when there was reason to suspect that the resident suffered a serious accident or injury. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Contact person for questions about the inspection |
| Jacquelyn Kabiri | Current Inspector | Inspector on-site during the inspection |
Inspection Report
Renewal
Deficiencies: 5
Feb 20, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations including failure to complete annual tuberculosis risk assessments for residents, medication management plan implementation issues with numerous medication administration errors, lack of documentation of annual contact with local emergency management, and incomplete fire drills across all shifts within the quarter.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that a risk assessment for tuberculosis (TB) was completed annually for each resident. |
| Facility failed to ensure that the medication management plan was implemented, resulting in 33 medication administration errors for one resident. |
| Facility failed to ensure medications were administered in accordance with prescriber’s instructions, including missed PRN medication administration and missed blood glucose checks. |
| Facility failed to ensure documentation of initial and annual contact with the local emergency coordinator as required in the emergency preparedness plan. |
| Facility failed to ensure that required fire drills were completed for each shift within the quarter. |
Report Facts
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 3
Staff interviews conducted: 6
Medication administration errors: 33
Medication doses administered when supposed to be held: 14
PRN medication doses not administered: 3
Blood glucose checks not performed: 16
Fire drills recorded: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Contact person for questions about the inspection |
| Staff 1 | Provided Medication Management Plan, Medication Error Policy, and confirmed emergency management contact and fire drill information | |
| Staff 2 | Interviewed regarding TB screenings and medication administration documentation | |
| Staff 4 | Provided copy of completed fire drills |
Inspection Report
Monitoring
Census: 55
Deficiencies: 1
Jun 14, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance; however, a violation unrelated to the self-report was identified involving failure to include Do Not Resuscitate (DNR) orders in individualized service plans (ISP). The licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that Do Not Resuscitate (DNR) orders were included in the individualized service plan (ISP). |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 55
Deficiencies: 6
Jun 14, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with applicable regulations and standards at the assisted living facility.
Findings
The inspection identified multiple violations including failure to register with the Department of State Police for sex offender alerts, unsecured resident records, lack of certification in special diet oversight, outdated medication reference materials, unlocked medication storage, and incomplete oxygen therapy orders.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure registration with the Department of State Police to receive notice of sex offender registration or reregistration within the same or contiguous zip code area. |
| Facility failed to ensure that all resident records retained at the facility were kept in a locked area. |
| Facility failed to ensure the special diet oversight included a certification that the requirements were met. |
| Facility failed to ensure that a pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old is readily accessible. |
| Facility failed to ensure that medication administered was stored in a locked medicine cabinet, container, or compartment. |
| Facility failed to ensure that oxygen therapy orders included the oxygen source such as compressed gas or concentrators. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Jun 6, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-06-02 regarding allegations in the areas of resident care and related services, and staffing and supervision.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in resident care and related services, including medication administration errors and documentation omissions.
Complaint Details
The complaint was substantiated in part; evidence supported some allegations related to resident care and related services but not all. A violation notice was issued related to the complaint.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that no medication shall be changed without a valid order from a physician or other prescriber. |
| Facility failed to ensure that Medication Administration Records include initials of direct care staff administering the medication, and any medication omissions. |
Report Facts
Residents present: 63
Resident records reviewed: 10
Resident interviews: 4
Staff interviews: 4
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Jan 10, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-12-08 regarding allegations in the areas of resident care and related services and admission, retention, and discharge of residents.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint received on 2022-12-08 regarding resident care and related services and admission, retention, and discharge of residents. The allegations were not substantiated.
Report Facts
Number of residents present: 58
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 58
Deficiencies: 0
Jan 10, 2023
Visit Reason
The inspection was conducted as a renewal inspection to ensure compliance prior to the expiration of the current license.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector observed medication administration, resident activities, and conducted interviews and record reviews without identifying any deficiencies.
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 4
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 30, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-05-16 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations. A violation was found related to the Buildings and Grounds standard 22VAC40-73-930-B concerning the failure to ensure a signaling device that permits staff to determine the origin of call signals. A violation notice was issued and a plan of correction was submitted.
Complaint Details
The complaint was related to issues with call bell alerts not indicating the origin of the signal to staff phones, resulting in staff being unable to determine which room the call was coming from. The evidence supported this issue as a violation of the Buildings and Grounds standard.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that in a building licensed to care for 20 or more residents under one roof, there is 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. |
Report Facts
Number of resident records reviewed: 8
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 8
Date of inspection visits: Inspection dates were May 19, 2022, June 2, 2022, and June 30, 2022
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Jun 30, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-06-24 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related to resident care and related services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 65
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Deficiencies: 0
Mar 1, 2022
Visit Reason
Unannounced focused monitoring visit to ensure correction of violations cited during the 2/18/2022 focused monitoring inspection.
Findings
All previous violations were found to have been corrected. The door to the servery on the memory care unit was functioning properly and could not be opened without the use of a fob device. No additional violations were cited.
Inspection Report
Monitoring
Deficiencies: 2
Feb 10, 2022
Visit Reason
An unannounced focused monitoring inspection was conducted regarding self-reported incidents at the facility between February 10 and February 18, 2022.
Findings
The facility failed to provide adequate supervision of a cognitively impaired resident who was found outside the secured care unit unsupervised, and the facility also failed to ensure that all doors, including the servery door, opened and closed properly, allowing resident access to restricted areas.
Deficiencies (2)
| Description |
|---|
| Failure to provide supervision of resident schedules, care, and activities, resulting in Resident #1 being unsupervised and whereabouts unknown for approximately 9 minutes on 2/4/2022. |
| Failure to ensure that all doors shall open and close readily and effectively, specifically the door to the servery area which was left open allowing Resident #1 unsupervised access. |
Report Facts
Staff working secured care unit on 2/4/2022 2pm-10pm shift: 5
Duration Resident #1 unsupervised: 9
Plan of correction completion deadline: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Inspector | Named as current inspector conducting the inspection |
| Jamie Eddy | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Census: 65
Deficiencies: 0
Dec 7, 2021
Visit Reason
An unannounced renewal study was conducted from December 7, 2021 to December 10, 2021 to review compliance with licensing requirements and regulations.
Findings
The inspection included review of resident and staff records, criminal background checks, and observation of resident activities and medication administration. No violations were cited during the inspection.
Inspection Report
Deficiencies: 0
Oct 20, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the area of resident care.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Inspection Report
Deficiencies: 0
Jul 21, 2021
Visit Reason
A non-mandated self-report inspection was initiated following a self-reported incident regarding allegations in the areas of resident care. The investigation was conducted by contacting the administrator and reviewing documentation.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Feb 22, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to review compliance with applicable standards and laws.
Findings
The inspection found no violations with applicable standards or law. No deficiencies were issued. Documentation including resident and staff records, background checks, and safety inspections were reviewed and found complete.
Report Facts
Inspection duration days: 4
Resident records reviewed: 4
Staff records reviewed: 4
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