VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The View at Goodwin Living, LLC
5000 Fairbanks Avenue
Alexandria, VA 22311

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Dec. 1, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/1/23 (9:00 AM - 5:20 PM) Number of residents present at the facility at the beginning of the inspection: 116 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 10 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activitity 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Evidence: No documentation was provided, during the inspection, to confirm that Staff #1 (hired 8/21/14) has current first aid certification. Staff #1's record contained current certification for CPR and AED, but not first aid.
Plan of Correction:	Address how the facility will correct the deficiency as it relates to the individual. The team member identified during the inspection completed first aid training on December 7, 2023. Address how the facility will act to protect residents in similar situations. All team members will be reviewed to ensure First Aid training is complete. Address what measures will be put into place or systemic changes made to ensure that the problem does not recur. Human Resources will monthly monitor CPR/First Aid training and provide direction to department leaders to remove from schedule if expired. Indicate how the facility will monitor its performance to make sure that solutions are sustained. Human Resources will monitor first aid training x3 months and report at next QAPI meeting The plan of correction must provide dates when corrective action will be completed. December 31, 2023
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that a tuberculosis risk assessment is completed annually for each resident, as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Residents #2, #4, and #5 contained tuberculosis screening and risk assessment forms, from November 2023. The results section was not completed on the tuberculosis risk assessment forms for Residents #2, #4, and #5.
Plan of Correction:	Address how the facility will correct the deficiency as it relates to the individual. Team members who completed the forms were in-serviced by the facility on 12/7/23. Address how the facility will act to protect residents in similar situations. Audit of all tuberculosis screening and risk assessment forms was completed. Address what measures will be put into place or systemic changes made to ensure that the problem does not recur. Inservice of licensed nurses regarding completion of screening as outlined by the tuberculosis screening and risk assessment form by Virginia Department of Health. Indicate how the facility will monitor its performance to make sure that solutions are sustained. Audit TB screens monthly for 3 months and report at the next QAPI meeting. The plan of correction must provide dates when corrective action will be completed. December 31, 2023
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure that a preliminary plan of care is developed, on or within seven days prior to the day a resident's admission. The preliminary plan shall be identified as such and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #8's record states that she was admitted on 10/25/23. Resident #8's individualized service plan (ISP) was not signed by the resident or her legal guardian.
Plan of Correction:	Address how the facility will correct the deficiency as it relates to the individual. Resident 8 service plan has been reviewed and signed by resident. Address how the facility will act to protect residents in similar situations. All residents who moved in the month of November and December will be audited to ensure their service plans are reviewed and signed by resident. Address what measures will be put into place or systemic changes made to ensure that the problem does not recur. Interdisciplinary Team Training on service plan regulations including resident signing service plan. Pre-move meetings will be planned within 7 days of move or on move in day for all new assisted living residents where service plan will be reviewed and signed. Indicate how the facility will monitor its performance to make sure that solutions are sustained. Resident Advocate or designee will monitor and track preliminary service plan signatures for all new residents x3 months and report at next QAPI meeting The plan of correction must provide dates when corrective action will be completed. December 31, 2023
Standard #:	22VAC40-73-680-D
Description:	Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician's order and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Medication administration for Resident #1 was observed during the inspection. Resident #1's medication administration record (MAR) states that she is supposed to receive Tacrolimus twice per day. Resident #1 did not receive Tacrolimus, ordered 11/17/23, during the morning medication administration as it was not available.
Plan of Correction:	Address how the facility will correct the deficiency as it relates to the individual. Resident medication was ordered by the facility on 12/7/23. Address how the facility will act to protect residents in similar situations. All medication currently administered by med techs will be audited for adequate supply. Address what measures will be put into place or systemic changes made to ensure that the problem does not recur. Med Techs will receive in-service by DON of timeliness and process of reordering medication. Indicate how the facility will monitor its performance to make sure that solutions are sustained. DON or designee will monitor each cart weekly x 4 weeks then monthly x 2 months for adequate supply and report at next QAPI meeting. The plan of correction must provide dates when corrective action will be completed. December 31, 2023