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: June 21, 2024

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness Additional Requirements for Facilities that Care for Adults with Cognitive Impairments Background Checks for Assisted Living Facilities Sworn Statement

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/21/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 19 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: Licensing Inspector observed residents participating in various activity programs and eating lunch. This LI also observed medications being administered to residents. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on record review and staff interview, the facility failed to review and update the written fall risk rating annually. Evidence: 1. Resident 2 was admitted on 8/9/2022 and the last fall risk rating was completed on 8/9/2022. 2. Resident 4 was admitted on 10/12/2021 and the last fall risk rating was completed on 10/12/2021.
Plan of Correction:	1. All residents on Assisted Living and the Terrace are at risk for this deficient practice. 2. All licensed nurses will be re-educated and newly hire licensed nurses will receive education upon hire on the Falls Risk Assessment policy and regulation. 3. All resident's charts on Assisted Living and the Terrace will be audited for compliance by July 8, 2024. Any resident that does not have an annual assessment will be completed at that time. 4. All charts will be audited for compliance during annual ISP meetings.