VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Goodwin House Bailey's Crossroads
3440 South Jefferson Street
Falls church, VA 22041
(703) 820-1488

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Feb. 2, 2020 and Feb. 27, 2020

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.

Technical Assistance:

Please ensure that all staff and resident tuberculosis screenings document the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Facility to submit Medication Management Plan to Licensing Inspector after modifications are completed for approval, including self-administration policies and procedures.

Comments:

An unannounced renewal study was conducted from from 8:45 a.m - 6:00 p.m. on 2/26/2020 and 8:45 a.m. on 2/27/2020. At the time of entrance 55 residents were in care in Assisted Living and Safe, Secure areas and 250 residents in Independent Living. The sample size consisted of eight resident records and five staff records. Six residents and staff staff were interviewed. Volunteer and pet records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 3/07/2019 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including exercise, Sonnets & Such, piano entertainment, Tea and Trivia in assisted living and pet visits, exercise, and coloring and singing with visiting children in the safe, secure area. Medication administration was observed with three staff and medication carts observed for PRN medications. Building and Grounds observed. Violations and risk ratings reviewed during 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) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observation, record review and interview, facility failed to ensure that the facility shall implement a written plan for medication management that shall address procedures for administering medication and shall include: methods for monitoring medication administration and the effective use of the MARs for documentation; methods to prevent the use of outdated or contaminated medications; and standard operating procedures, including the facility's standard dosing schedule. Evidence: During observation of medication administration on 2/26/2020, Staff #1 monitored Resident #2 during self-administration of eye drops (Azpot 1% and Pilocarpine 2%) and nasal spray (Fluticasone 50 MCG) and resident contaminated the two bottles of eye drops during administration and nasal spray bottle was returned without cleaning the tip; Staff #1 administered Resident #1's Gabapentin 300 mg (ordered 6/4/2019, 1 capsule three times daily) at 9:06 a.m. and then placed a capsule into a bag for Resident #1 to take to his room for self-administration at 1:00 p.m. and staff documented on MAR; Resident #10's Famotidine 40 mg tablet scheduled at 9:00 a.m. was observed administered and documented at 11:38 a.m.; and Resident #1's Glucagon 1 mg injection in medication closet expired 12/2019 and Resident #9's Magnesium in room expired 4/2019.
Plan of Correction:	Discrepancies and violations for the above listed residents were resolved as follows; completion of medication self-administration assessment as follow-up with residents #1 and #2; necessary changes were made accordingly. New physician?s order was obtained to move scheduled 9am medication of resident #10 into open med pass per facility standard dosing schedule. Expired medications belonging to residents #1 and #9 were disposed of; resident #9 was provided with box for in-room medication storage and physical changes will be made to the medication room where medications of resident #1 are stored. Limiting storage usage of top cabinet shelving by physically altering the cabinetry will be completed so that all stored medications and supplies are within sight of the individual completing the audit. The Goodwin House Bailey?s Crossroads medication management plan will be updated to include detailed information on self-administration of medication, standard dosing schedule and effective use of the MAR. Education sessions will be provided to all nurses and medication aides to review areas of violation and updates to plan. Medication observation will be performed by the Charge Nurse quarterly for 2 cycles and then semi-annually. Persons Responsible: Nurse Staff Educator, Assisted Living Administrator
Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions. Evidence: Resident #4's resides in safe, secure area with an order dated 7/24/2019 to "crush medications and use pudding if medication is refused" that was not observed during medication administration on 2/26/2020 at 11:13 a.m.; Staff #4 discarded Resident #4's medications (Sennosides 8.6mg-docusate sodium 50 mg tablet, Amlodipine 10 mg tablet, Losartan 25 mg tablet, Acetaminophen 325 mg tablet, Omeprazole 40 mg capsule, Lorazepam 2 mg/ml, Depakote Sprinkles 125 mg capsule) after four attempts to encourage resident to take the medications that were not crushed and were not offered in pudding as ordered.
Plan of Correction:	Immediately obtained updated physician?s order for resident #4 to crush all medications, unless contraindicated, and mix with pudding for administration. A full audit will be completed for all residents who have orders to crush medications with the goal of simplifying and clarifying multiple-part orders. Collaborated with medical records team to alter eMAR to allow for staff to view full physician?s orders for medication administration within special instructions section, as the previous character limit prevented staff from seeing entire order at a glance. Education sessions will be provided to all nurses and medication aides as review. Person Responsible: Nurse Staff Educator
Standard #:	22VAC40-73-680-H
Description:	Base on observation, record review and interview, facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents. Evidence: During observation of medication administration at 11:38 a.m. on 2/26/2020, Licensing Inspector observed Staff #1 document the administration of Dorzolamide 2% eye drops and did not observe the administration of the medication to Resident #10; and staff stated the medication had been administered earlier in the resident's room.
Plan of Correction:	Staff counseled on appropriate medication administration practices and effective use of MAR. Education of all nurses and medication aides on Medication Administration Policy; including importance of timely documentation on MAR. AL Administrator to complete quarterly audits of MAR for 2 cycles and then semi-annually. Person Responsible: Nurse Staff Educator to complete education, Assisted Living Administrator to complete audits.