VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Goodwin House Alexandria
4800 Fillmore Ave
Alexandria, VA 22311
(703) 824-1000

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: June 9, 2022

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 GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/9/22 (9:00 AM ? 6:00 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An unannounced monitoring inspection was conducted on 6/9/22. At the time of entrance, 49 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed and interviews were conducted. The sample size consisted of eight resident records, four staff records, and four individual interviews. Background checks for all new staff, hired since the last inspection, were reviewed for completion. Violations were discussed and an exit meeting was 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure that each resident is assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, prior to his/her admission to the safe, secure environment. Evidence: The record for Resident #4 was reviewed during the inspection. Resident #4's Assessment of Serious Cognitive Impairment form, dated 8/30/21, states that the resident has the ability to recognize danger or protect his own safety and welfare.
Plan of Correction:	The Assessment of Serious Cognitive Impairment forms for all residents living in the safe and secured environment will be audited by the Administrator. If the document is incomplete, the resident?s physician will complete a new assessment. The Administrator will review all new Assessments of Serious Cognitive Impairment for completion prior to a resident admission to the safe and secured environment. Responsible Person: Assisted Living Administrator
Standard #:	22VAC40-73-660-B
Description:	Based on observation and record review, the facility failed to ensure that medication storage is limited to an out-of-sight place, in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering medication. Evidence: A tube of topical antibiotic ointment was observed on Resident #4?s bathroom counter. Resident #4?s UAI, updated 3/9/22, states that the resident needs his medications to be administered/monitored by a lay person.
Plan of Correction:	The safe and secured environment apartments will be audited monthly for any medication by a designated Registered Medication Aide. Documentation of this audit will be submitted to the Administrator. Education on medications in resident rooms will be sent out to family members. Responsible Person: Assisted Living Administrator
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: PRN methocarbamol, ordered 3/1/21 for Resident #9, was not present during the medication cart inspection. Facility staff confirmed that the medication was not present during the medication cart inspection.
Plan of Correction:	The Assisted Living Charge Nurse will review PRN medications for all Assisted Living residents. The PRN and expired medication audit form will be revised to include a receipt column for Registered Medication Aides to initial when the medication is received. Responsible Person: Assisted Living Charge Nurse