Virginia DSS · Assisted Living Facility

The View Alexandria by Goodwin Living

📍 5000 Fairbanks Avenue, Alexandria, VA, 22311

ID 48249One Year licenseActive
12
Inspections
On record
5
With violations
Visits that cited something
7
Clean visits
Nothing cited
33
Violations cited
Individual findings
27
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

The View Alexandria by Goodwin Living was inspected 12 times between July 15, 2022 and January 23, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 33 violations under 27 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
01/31/2027
Administrator
Deborah Kline
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Non-Ambulatory · Assisted Living

Inspection History

12

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

January 23, 2026Complaint survey0 violations
Inspection dates
01/23/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2026 Time in: 2:23 PM Time out: 4:54 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/15/2026 regarding allegations in the area(s) of: General Provisions, Administration and Administrative Services, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector (LI) observed residents entering and exiting the facility for community outings, interacting with peers and staff, and participating in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 16, 2025Inspection7 violations
Inspection dates
12/16/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
The licensing inspector reviewed the following inspections with the facility: 22VAC-40-73-50, 22VAC-40-73-210, 22VAC-40-73-450, and 22VAC-40-73-950.
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: 12/16/2025 Time in: 10:11 AM Time out: 7:06 PM 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: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 7 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for community outings, residents engaged with vendors selling Christmas items, residents participating in scheduled activities, and residents dining for lunch and dinner. Additional Comments/Discussion: N/A 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-220-A
Based on record review and staff interview, the facility failed to ensure when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies: before direct care or companion services are initiated, the facility should obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it was acceptable, and provide notification to the home care organization regarding any needed changes. The facility should provide orientation and training to private duty personnel regarding the facility’s policies and procedures related to the duties of private duty personnel.
Evidence
  1. Private duty personnel 5 and private duty personnel 6’s records did not include written information on the type and frequency of the services to be delivered to the resident by private duty personnel.
  2. Private duty personnel 5 and private duty personnel 6’s records did not include documentation of orientation and training regarding the facility’s policies and procedures related to the duties of private duty personnel.
  3. During the onsite inspection, 12/16/2025, staff 10 confirmed that private duty 5 and private duty personnel 6’s records did not include written information on the type and frequency of the services to be delivered to the residents by private duty personnel. Also, staff 10 confirmed that private duty personnel 5 and private duty personnel 6’s records did not include documentation of orientation and training regarding the facility’s policies and procedures related to the duties of private duty personnel.
Plan of correction
The records for private duty personnel 5 and 6 were updated to include written information on the type and frequency of services to be delivered to the resident by private duty personnel, and documentation of orientation and training regarding the facility’s policies and procedures related to the duties of private duty personnel. A checklist for required information in private duty personnel files will be developed and used for any new private duty personnel. The Social Worker, or designee, will audit existing private duty personnel files using the checklist to verify that they include written information on the type and frequency of services to be delivered to the resident by private duty personnel and documentation of orientation and training regarding the facility’s policies and procedures related to the duties of private duty personnel.
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating should be reviewed and updated under each of the following circumstances: at least annually and after a fall.
Evidence
  1. The Incident Report (witnessed and unwitnessed fall incidents) indicated that resident 3 had a fall on the following dates: 06/16/2025, 10/18/2025, 10/20/2025, 10/21/2025, 10/27/2025, 10/28/2025 and 10/29/2025. Resident 3’srecords did not include a post fall risk rating for those dates.
  2. During the onsite inspection, 12/16/2025, staff 10 confirmed that resident 3’s records did not include an initial fall risk rating or fall risk ratings after the following falls: 06/16/2025, 10/18/2025, 10/20/2025, 10/21/2025, 10/27/2025, 10/28/2025 and 10/29/2025.
Plan of correction
Resident 3 was transferred to the hospital on 10/30/25 and did not return to the facility. An audit of residents who have fallen in the last year will be conducted by 2/14/26 by the Director of Nursing, or designee, and fall risk ratings will be reviewed and updated if indicated. Licensed nurses will be re-educated on the requirement to review and update the fall risk rating after a fall by 2/28/26. Moving forward, the Director of Nursing, or her designee, will audit residents who have fallen weekly and update the fall risk rating if indicated. For the next three months, the results of the weekly fall audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications should administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident 5 was prescribed Hydralazine HCL 50 MG (give 1 tablet by mouth three times a day). August 2025 MAR indicated that Hydralazine HCL 50 MG was not documented as administered on 08/21/2025 at 1 pm.
  2. During the onsite inspection, 12/10/2025, staff 10 confirmed that August 2025 MAR indicated that resident 5’s Hydralazine HCL 50 MG was not documented as administered on 08/21/2025.
  3. Resident 8 was prescribed the following routine evening medications: Amlodarone HCL 200 MG (give 1 tablet by mouth one time a day), Atorvastatin 20 MG (give 1 tablet by mouth one time a day), Trazodone HCL 100 MG (give 1 tablet by mouth one time a day), Mexiletine HCL 150 MG (give 1 capsule by mouth two times a day), and Pradaxa 150 MG, Sacubitril-Valsartan (give 1 tablet by mouth two times a day.
  4. The May 2025 MAR indicated that resident 8’s routine evening medications were not documented as administered on 05/15/2025: Amlodarone HCL 200 MG, Atorvastatin 20 MG, Trazodone HCL 100 MG, Mexiletine HCL 150 MG, Pradaxa 150 MG, Sacubitril-Valsartan. Resident 8’s May 2025 MAR and progress notes did not include a reason for the missed doses or insufficient documentation.
  5. During the onsite inspection, 12/10/2025, staff 10 confirmed that May 2025 MAR indicated that resident 8’s routine evening medications (Amlodarone HCL 200 MG, Atorvastatin 20 MG, Trazodone HCL 100 MG, Mexiletine HCL 150 MG, Pradaxa 150 MG, Sacubitril-Valsartan) was not documented as administered on 05/15/2025.
Plan of correction
Registered Medication Aides and Nurses will be re-educated by the Director of Nursing, or designee, regarding proper documentation of medications administered by 2/14/26. An audit of missing medication documentation will be conducted by the AL Manager, or designee, for the month of January 2026 to identify any other instances where documentation of medications administered was missed. If additional instances are identified, they will be investigated and team members will be re-educated. Audits of late medication will continue to be conducted by the AL Manager weekly for the next four weeks and then monthly for three months to verify that medications are documented when administered. The results of the medication documentation audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-240-F
Based on record review and staff interview, the facility failed to ensure that prior to beginning volunteer service, all volunteers should attend an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements. Volunteers should sign and date a statement that they received and understood this information.
Evidence
  1. Upon request the facility did not provide documentation that volunteer 7 and volunteer 8 signed and dated a statement that they received and participated in an orientation.
  2. During the onsite inspection, 12/16/2025, staff 10 confirmed that volunteer 7 and volunteer 8’s records did not include an orientation that included information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements.
Plan of correction
The records for volunteers 7 and 8 were updated to include a signed and dated statement that they received and participated in an orientation that included information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor and reporting requirements. A checklist for required information in volunteer files was developed and will be used for any new volunteers. The Volunteer Coordinator, or designee, will audit existing volunteer files using the checklist to verify that they include a signed and dated statement that they received and participated in an orientation that included information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor and reporting requirements.
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section should be reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person.
Evidence
  1. Upon request the facility did not provide documentation that the procedures for resident emergencies were reviewed at least every six months.
  2. During the onsite inspection, 12/16/2025, staff 10 confirmed that the facility did not provide documentation that procedures for resident emergencies were reviewed every 6 months.
Plan of correction
Post drill review materials were updated to include procedures for resident emergencies by the Director of Facilities. Moving forward, procedures for resident emergencies will be reviewed with team members following each drill. Drill logs and sign-in sheets will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings to verify correct practice. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-880-B
Based on observation and staff interview, the facility failed to ensure that a temperature of at least 72 Fahrenheit should be maintained in all areas used by residents during hours when residents are normally awake. During night hours, when residents are asleep, a temperature of at least 68 Fahrenheit should be maintained. This standard applies unless otherwise mandated by federal or state authorities.
Evidence
  1. During a tour of the facility, 12/16/2025, licensing inspector noted that the temperature was low in the main lobby and within the elevator.
  2. On 12/16/2025, licensing inspector requested staff 11 to take a temperature of the elevator and main lobby. The temperature of the elevator was 59.2 and the main lobby was 66.4.
  3. During the onsite inspection, 12/16/2025, staff 10 confirmed that the temperatures in the elevator and main lobby were below 72 Fahrenheit.
  4. Picture was taken.
Plan of correction
The low temperatures in the main lobby and elevator shafts were related to unusually cold outside air penetration when the main lobby doors open and close, and missing vent covers in the elevator hoistways allowing outside air into the elevator shaft. The temperature in the lobby was immediately addressed by posting signage asking visitors to wait for one set of doors to close before opening the next one in order to minimize outside air penetration. Throw blankets were also made available in lobby seating areas for the comfort of residents who are using the lobby space. Three vendors conducted site assessments for the installation of air curtains at the main entry doors; awaiting proposals. In order to properly replace the missing vent covers in the elevator hositways, DMV Elevator was contracted to install MOD dampers tied into the fire alarm system that will allow the ventilation to remain closed except when there is a fire emergency. Parts are not expected to be available until July 2026 due to supply chain delays.
22VAC40-73-280-B
Based on record review and staff interview, the facility failed to maintain a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan should be directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. The written plan stated “...is licensed for 200 residents, up to 40 of whom may be non-ambulatory. The facility has at least 2 team members alert, awake and on duty 24 hours a day, 7 days a week.”
  2. The residential listing report and staff 10 confirmed that there were 32 non-ambulatory residents included in the census.
  3. During the onsite inspection, 12/16/2025, staff 9 confirmed that the facility’s staffing schedule: first shift (7 am – 3 pm), 3 medication technicians (MT) and 6 certified nursing assistants (CNA); second shift (3 pm – 11 pm), 3 MTs and 5 CNAs; and third shift (11 pm – 7 am), 1 MT and 3 CNAs.
  4. During the onsite inspection, 12/16/2025, staff 10 confirmed that the written plan did not accurately specify the number and type of direct care staff required to meet the day-to-day, routine direct care needs and met the actual resident acuity levels and individualized care needs.
Plan of correction
The written plan was updated to reflect the facility’s current staffing. It will be included in the annual policy and procedure review process moving forward to verify that it continues to reflect current practice.
October 23, 2024Inspection19 violations
Inspection dates
10/23/2024, 10/24/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
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: Date: 10/23/2024 Time In: 9:30 AM Time Out: 4:31 PM Date: 10/24/2024 Time In: 9:42 AM Time Out: 5:58 PM 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: 128 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) toured the physical plant of the facility. LI observed residents engaging in individual pursuits, such as entering and exiting the facility for community outings, interacting with staff and peers, dining for breakfast, lunch, and dinner, watching television in the common areas, participating in the various activities scheduled throughout the day(s). LI observed a medication pass. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-830-E
Based on facility record review and staff interview, the facility failed to ensure that a written response to the council was provided prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. Resident Council meetings were facilitated by residents on 01/12/2024, 02/09/2024, 02/23/2024, 03/08/2024, 04/12/2024, 05/10/2024, 06/14/2024, 06/15/2024, 06/28/2024, 08/09/2024, and 09/13/2024. Recommendations were made by the residents at each of these meetings. The facility did not provide a written response to the residents regarding their recommendations.
  2. On 10/23/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that there was not a written response provided prior to each resident council meeting.
Plan of correction
The Executive Director began providing written responses to the Resident Council regarding recommendations made by the council for resolution of problems or concerns beginning with the Resident Council Executive Committee meeting held on 11/8/24. A copy of the Executive Director’s written response is placed in the Resident Council minutes binder available to all residents in the community’s Library.
22VAC40-73-990-C
Based on facility record review, the facility failed to ensure that at least every six months, all staff currently on duty on each shift participated in an exercise in which resident emergencies were practiced.
Evidence
  1. Resident emergency drills were conducted on 11/20/2023 (missing resident), 03/12/2024 (elopement) and 03/28/2024 (choking). The drills were not conducted on each shift.
  2. On 11/20/2023 at 10:30 AM, 13 staff members participated in the missing resident drill, but 16 employees clocked in for the morning shift.
  3. On 03/12/2024 at 2:12 PM, an elopement drill was conducted.
  4. On 03/28/2024 (no identified time or shift noted), 11 staff members signed the in-service training stating participation in the choking drill, but 34 staff members clocked in for the day.
Plan of correction
The resident emergency drill schedule was revised by the Director of Facilities to ensure that each drill is performed on all three shifts during the month it is held. The next drill is scheduled for March 2025. Following each drill, sign-in sheets will be verified against payroll records to verify that all staff on duty at the time of the drill participated in the drill. Any exceptions (i.e., staff member on duty but attending an off-campus event during drill) will be documented on the drill logs. Drill logs and sign-in sheets will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings to verify correct practice. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-240-F
Based on volunteer record review and staff interview, the facility failed to ensure that prior to beginning volunteer service, all volunteers attended an orientation. Volunteers signed and dated a statement that they have received and understand the information.
Evidence
  1. Volunteer 12 records did not include a signed and dated statement indicating orientation completion.
  2. On 10/24/2024, licensing inspector (LI) interviewed Staff 10 who stated, “I reviewed orientation with our volunteers. I take them on a tour and get signatures after the tour. I didn’t take Volunteer 12 on a tour, so I didn’t get a signature from him.”
Plan of correction
The volunteer orientation was reviewed with Volunteer #12 by the Chaplain and signed by Volunteer #12 on 11/29/24. There are no other active volunteers at this time. Moving forward, new volunteers will complete a structured orientation meeting with a member of the Life Enrichment staff prior to starting volunteer service. At this orientation, and each subsequent meeting, the new volunteer will be scheduled for a follow-up meeting for approximately six months in the future to review their feedback and additional education. The Life Enrichment Director will maintain a schedule of volunteer training.
22VAC40-73-950-E
Based on facility record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all residents and volunteers with emphasis placed on each individual’s respective responsibilities. Documentation that the review was conducted was indicated by having each individual sign and date when completed.
Evidence
  1. Volunteer 12’s record did not include a signed emergency preparedness and response plan orientation form. The records did not include documentation that a semi-annual review was conducted.
  2. On 10/23/2024, licensing inspector (LI) interviewed Staff 10 who confirmed that Volunteer 12 did not sign his orientation training.
  3. On 10/24/2024, LI interviewed Staff 7 who provided documentation of required semi-annual trainings by staff and confirmed that Volunteer 12 did not complete the semi-annual review. 4. The emergency preparedness and response plan was reviewed with residents at the town hall meetings on 05/17/2023, 11/21/2023, and 06/19/2024. Residents did not sign or date the review.
  4. On 10/23/2024, LI interviewed Staff 7 who confirmed that residents did not sign and date the emergency preparedness and response plan review.
  5. The “Emergency Preparedness Review” stated, “reviewed emergency preparedness steps and procedures with residents.” The review did not include alerting personnel, implementing evacuation, shelter in place, and relocation procedures, using maintaining, and operating emergency equipment, accessing emergency medical information, locating and shutting off utilities, and utilizing community support services.
Plan of correction
Education on resident emergency procedures was provided at the Town Hall meeting on 11/20/24 by the Executive Director for those residents in attendance. Moving forward, resident emergency procedures will be reviewed upon admission by the Resident Services Coordinator, and by the Executive Director, or her designee, at monthly floor meetings with current residents of that floor. The Resident Services Coordinator will follow up with any residents who do not attend the floor meeting to review resident emergency procedures before the end of the month. Floor meetings are conducted on each floor every six months. Signed records of emergency procedures review will be maintained by the Resident Services Coordinator for each resident and reviewed at the quarterly Quality Assurance and Performance Improvement meetings for compliance. If continued non-compliance is observed, additional corrective actions will be implemented. Emergency preparedness and response education was provided to volunteer #12 on 11/29/24 by the Chaplain. There are no other active volunteers at this time. Moving forward, new volunteers will complete a structured orientation meeting that includes emergency preparedness and response education with a member of the Life Enrichment staff prior to starting volunteer service. At this orientation, and each subsequent meeting, the new volunteer will be scheduled for a follow-up meeting for approximately six months in the future to review their feedback and the bi-annual review of emergency preparedness and response education. The Life Enrichment Director will maintain a schedule of volunteer training.
22VAC40-73-950-B
Based on facility record review and staff interview, the facility failed to ensure that the emergency preparedness and response plan included a description of the generator’s capacity to provide sufficient power for the operation of lighting, ventilation, temperature control, supplied oxygen, and refrigeration.
Evidence
  1. Licensing inspector (LI) reviewed the emergency preparedness and response plan on 10/23/2024. The plan did not include the generator’s capacity.
  2. On 10/24/2024, licensing inspector (LI) interviewed Staff 7 who stated, she and Staff 9 reviewed the emergency preparedness plan and realized that the capacity of the generator was not included. Staff 7 stated, “we added the capacity to the emergency plan yesterday evening.”
Plan of correction
The emergency preparedness and response plan was updated at the time of the survey (10/23/24) to include a description of the generator’s capacity.
22VAC40-73-650-E
Based on resident record review, the facility failed to ensure that the resident’s record contained the physician’s or other prescriber’s signed written order or a dated notation of the physician’s or other prescriber’s oral order.
Evidence
  1. Resident 7 (admit date, 09/24/2024) had orders, Comprehensive Metabolic Panel, Magnesium (order date, 10/08/2024) and CBC without Differential (order date, 10/08/2024).
  2. LI reviewed Resident 7’s record on 10/24/2024 and noted that the orders were unsigned by a physician.
  3. Resident 7’s (admit date, 09/24/2024) physical examination listed medications (Rytary 48.75-195 MG, Nifedipine ER 30 MG, Olmesartan Medoxomil 20 MG, Carvedilol 12.5 MG, Hydrochlorothiazide 12.5 MG, Rytary 36.25-145 MG) that were not included on the physician order summary.
  4. On 10/24/2024, licensing inspector (LI) interviewed Staff 8 who stated that’s weird. LI provided Staff 8 with a picture of the unsigned physician’s orders. Staff 8 confirmed that the physician orders were not signed.
Plan of correction
The unsigned lab orders for Resident #7 were determined to be computer-generated push notices created when the lab result was transmitted from the lab back to the electronic medical record system and were deleted. The original signed lab orders, dated 10/4/24, were also found on the chart. The medication orders found in the resident’s admission physical examination were not entered onto the physician order summary for signature because the resident self-administers and orders her own medications. The facility does not maintain an active physician order sheet for residents who self-administer and order their own medications. An audit was completed by the Director of Nursing on 2/11/25 to identify other computer-generated lab push notices that may appear to be unsigned orders. Those found were deleted. Moving forward, orders will be audited weekly by the Director of Nursing, or her designee, through 4/1/25 to verify that any computer-generated lab push notices were deleted. Effective 4/1/25, the facility will be transitioning to a new electronic medical record system that should eliminate this problem. The results of the audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented
22VAC40-73-660-A-1
Based on licensing inspector (LI) observation, the facility failed to ensure that medications were stored in a manner consistent with current standards of practice and that the storage area was locked.
Evidence
  1. On 10/23/2024, LI was preparing to observe a medication pass and noticed that the medication cart was open.
  2. On 10/23/2024, while observing a medication pass, LI observed Staff 13 walk into Resident 9’s room to administer medications and left the medication on top of the cart.
  3. Photo evidence taken.
Plan of correction
The AL Manager conducted observations of all medication carts at the time of the survey (10/24/24) and found them to be locked. Staff #13 was educated on 10/24/24 by the Director of Nursing regarding proper storage of medications. Education on proper storage of medications will be provided to Registered Medication Aides and Licensed Nurses by 2/14/25 by the Director of Nursing, or her designee. Medication pass observations will be conducted by the Director of Nursing, or her designee, on at least four staff per month for the next three months to verify proper practice. The results of the medication pass observations will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-680-M
Based on resident record review and staff interview, the facility failed to ensure that the medications ordered for PRN administration were available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. Resident 5’s (admit date, 02/13/2023) Polyethylene Glycol 3350 17-gram oral powder packet (1 packet by mouth once daily as needed. Mix in 8 oz. liquid of choice for constipation) was not available for administration.
  2. On 10/24/2024, during the medication review, Staff 14 gave licensing inspector (LI) Resident 4’s (admit date, 07/18/2023) Polyethylene Glycol 3350 17-gram oral powder packet. Resident 4 is Resident 5’s wife but they reside in two separate apartments.
  3. On 10/24/2024, LI interviewed Staff 14 who confirmed that Resident 5’s Polyethylene Glycol 3350 17-gram oral powder packet was not available for administration.
Plan of correction
The Polyethylene Glycol was re-ordered for Resident #5 at the time of the survey (10/24/24) and obtained. Education on timely re-ordering of medications will be provided to Registered Medication Aides and Licensed Nurses by 2/14/25 by the Director of Nursing, or her designee. A MAR-to-Cart audit was conducted for PRN orders on 2/10/25 to verify that ordered medications were present for administration. Any medications not found were re-ordered. Moving forward, a MAR-to-Cart audit of PRN orders will be conducted monthly for three months, and then quarterly for three quarters by the Director of Nursing, or her designee. The results of the MAR-to-Cart audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
63.2-1808-A-4
Based on licensing inspector (LI) observation, the facility failed to ensure that a resident was afforded confidential treatment of his personal affairs and records.
Evidence
  1. On 10/24/2024, while LI observed the administration of medication, Staff 13 did not lock the computer screen, which showed a resident’s record.
  2. Picture evidence taken.
Plan of correction
The AL Manager conducted observations of all medication carts at the time of the survey (10/24/24) and found all computer screens to be locked. Staff #13 was educated on 10/24/24 by the Director of Nursing regarding protection of residents’ confidential records. Education on protection of residents’ confidential records will be provided by 2/14/25 by the Director of Nursing, or her designee, to Registered Medication Aides and Licensed Nurses. Medication pass observations will be conducted by the Director of Nursing, or her designee, on at least four staff per month for the next three months to verify protection of residents’ confidential records during medication administration. The results of the medication pass observations will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-680-B
Based on licensing inspector (LI) observation, the facility failed to ensure that medications were administered one hour before and one hour after the facility’s standard dosing schedule.
Evidence
  1. On 10/23/2024, LI observed Staff 13 administer Resident 4’s (admit date, 07/18/2023) afternoon medication that was scheduled for 12:00 PM, Lorazepam 0.5 MG (1 tablet by mouth twice daily). Staff 13 administered and documented the medication at 1:19 PM.
  2. On 10/23/2024, LI interviewed Staff 13 who stated, “yes, it is scheduled for noon, but she likes to take it at 1:00 PM. This preference was not indicated on Resident 4’s ISP.
Plan of correction
The medication administration time for Resident #4’s Lorazepam was adjusted per her preference. Staff #13 was educated on 2/10/25 by Director of Nursing regarding timely administration of medications and how to adjust administration times according to resident preferences. Education on timely administration of medications and how to adjust administration times according to resident preferences will be provided to Registered Medication Aides and Licensed Nurses by 2/14/25 by the Director of Nursing, or her designee. An audit of late medication administration was conducted by the AL Manager over the month of December 2024 to identify any other instances where time adjustment was needed per resident preference. No other instances were identified. Audits of late medication will continue to be conducted by the AL Manager weekly for the next four weeks and then monthly for three months to verify that no further adjustments are needed to administration times. The results of the medication pass observations will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-280-B
Based on facility record review and staff interview, the facility failed to ensure that the assisted living facility maintained a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. The plan was directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. On 10/23/2024, licensing inspector (LI) requested the staffing plan.
  2. On 10/23/2024, LI interviewed Staff 8 who stated being unsure if the facility had a staffing plan but would look into it. Staff 8 returned to LI requesting more information on what the staffing plan consisted of. Staff 8 repeated that she would search for the plan. Staff 8 returned and stated, “we do not have that.”
Plan of correction
A written staffing plan was developed by the Executive Director and Director of Nursing that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. The plan was submitted to the Goodwin Living Policy Review Committee for review and approval at the next committee meeting on 4/24/25.
22VAC40-73-870-A
Based on licensing inspector (LI) observation, the facility failed to ensure that the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 10/23/2024, during a tour of the facility, LI observed the first-floor utility room’s laundry table covered with miscellaneous items: dollar tree basket, spray bottle, and clothing. This utility room is also used by residents.
  2. On 10/23/2024, during a tour of the facility, LI observed that the first-floor utility room bathroom’s emergency signaling device was missing the pull string. This bathroom is used by guests and residents.
  3. On 10/23/2024, during a tour of the facility, LI observed the second-floor utility room, which had a rollator, Hoyer lift, office desk, and wheelchair in the middle of the laundry area’s floor. This utility room is also used by residents.
  4. On 10/23/2024, during a tour of the facility, LI observed the second, fourth, and fifth floor’s unlocked custodial closets with the electrical boxes open, with the cords exposed.
  5. On 10/23/2024, during a tour of the facility, LI observed the bookcase’s wood panel was peeling and ragged. The bookcase is embedded in the hallway wall where resident apartments are located.
  6. Photo evidence taken.
Plan of correction
Clutter was cleared from the 1st and 2nd floor utility rooms at the time of survey (10/24/24). The missing pull cord was replaced on the first-floor utility room bathroom’s emergency signaling device at the time of survey (10/24/24). The exposed cords in the second, fourth and fifth floor utility boxes were confirmed to be telephone and cable television cords that carried no electrical current. Locks were ordered for the closets and will be installed upon arrival. The peeling panel on the bookcase was sanded and refinished the week following the survey (10/28/24). Environmental rounds are conducted weekly by the Director of Facilities and Director of Environmental Services, or their designees, to check for clutter and damage to the building and its furnishings. If issues are found, they will be corrected on the spot, or a work order will be entered for further follow-up.
22VAC40-73-320-A
Based on resident record review and staff interview, the facility failed to ensure that within 30 days preceding admission, a person had a physical examination by an independent physician. The report was on file and contained the following: person’s address and telephone number, significant medical history, general physical condition, and any recommendations for therapy.
Evidence
  1. Resident 4’s (admit date, 07/18/2023) physical examination was completed on 08/22/2022.
  2. On 10/24/2024, licensing inspector (LI) interviewed Staff 7 who stated, Resident 4 moved from the health center to assisted living (AL) on 07/18/2023. The health center is the building next door, that is owned by the facility. “Maybe the conversation started to place Resident 4 in AL, and they could not do it. I’m unsure why they used an AL health and physical form, but she did move over from our health center.”
  3. Resident 7’s (admit date, 09/24/2024) physical examination completed on 09/13/2024 was missing the address, telephone number, significant medical history, general physical condition, and recommendation for therapy.
Plan of correction
Resident #4 remains in the facility in stable condition. She has had multiple physician visits since admission. Resident #7’s physical examination report was updated to include the missing address, telephone number, significant medical history, general physical condition, and recommendations for therapy. An audit of admissions for the last three months was conducted by the Executive Director to verify that their physician examination was completed within 30 days prior to admission and the written report was complete. Incomplete records were updated to reflect complete information. Moving forward, the Resident Services Coordinator, or her designee, will review all admission documentation for completion and timeliness at the pre-admission meeting. If the physician examination form is found to be incomplete or out of date, it will be corrected or re-done prior to the resident moving into the facility.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 6’s (admit date, 06/01/2019) special diet (pureed solids with nectar thickened liquids, order date 08/02/2024) was not identified as a need on the ISP (effective date, 10/14/2024).
Plan of correction
The ISP for Resident #6 was updated to reflect his current diet order. An audit was conducted by the Director of Nursing on 2/10/25 to identify other resident’s whose ISPs did not reflect their current diet orders. If discrepancies were identified, the ISP was updated to reflect the current order. Education on timely updating of ISPs will be provided to Licensed Nurses and other staff who update the ISP by 2/14/25 by the Director of Nursing, or her designee. Random audits of at least six ISPs per month will be conducted by the Director of Nursing, or her designee, for the next three months to verify that they are being reviewed and updated at least once every 12 months. The results of the audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. Resident 5’s (admit date, 02/13/2023) Istradefylline (Nourianz) 200 MG (1 tab by mouth once daily for Parkinson’s disease) was not available for administration.
  2. On 10/24/2024, licensing inspector (LI) interviewed Staff 14 who confirmed the medication was not available for administration. Staff 14 stated that “it was on back order. The pharmacy that dispenses it said that couldn’t dispense it.”
  3. Istradefylline 200 MG was ordered on 09/07/2024. The medication was not administered as ordered from 09/07/2024 to the time the LI was onsite for the inspection.
  4. The medication management plan does not state a procedure for filling and refilling medications to avoid missed dosages.
Plan of correction
The Istradefylline for Resident #5 was only available from a specialty pharmacy and was delayed pending multiple layers of approval. It was received on 11/11/24. Resident #5 was seen by the nurse practitioner on 9/17/24, and by the physician on 9/30/24 and 10/11/24 with no alternative medication orders given. Education will be provided to all Registered Medication Aides and Licensed Nurses by 2/14/25 regarding procedure when a medication is not available. Medication records will be audited by the Director of Nursing, or her designee, to verify that medications are available for administration by 2/14/25. The medication management plan was updated to include a procedure for filling and refilling medications to avoid missed dosages. Moving forward, the Director of Nursing, or her designee, will audit medication records weekly for four weeks, then monthly for an additional three months to verify that medications are available for administration. The results of these audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-950-A
Based on facility record review and staff interview, the facility failed to ensure to develop a written emergency preparedness and response plan that addressed documentation of initial and annual contact with the local emergency coordinator.
Evidence
  1. The emergency preparedness and response plan did not include initial or annual contact with the local emergency coordinator.
  2. On 10/23/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that the emergency preparedness and response plan did not include initial and annual contact with local emergency coordinator.
Plan of correction
The Director of Facilities reached out to the Alexandria Office of Emergency Management (OEM) to request an appointment for review of the Emergency Preparedness and Response Plan. The meeting with Alexandria OEM to review the Emergency Preparedness and Response Plan was held on 2/10/25 and will be scheduled annually moving forward. The Emergency Preparedness and Response Plan was approved by OEM for the current year.
22VAC40-73-310-B
Based on resident record review and staff interview, the facility failed to ensure that an individual was not admitted before a determination was made that the facility can meet the needs of the individual.
Evidence
  1. Resident 7’s (admit date, 09/24/2024) records did not include a documented interview between the administrator or a designee.
  2. During the findings review on 10/24/2024, Staff 7 stated that she was a new administrator and may have the missing documents. On 10/25/2024, Staff 7 emailed licensing inspector (LI) Resident 7’s admission documents, the documented interview was not included.
Plan of correction
An interview was conducted with Resident #7 at the time of the pre-admission UAI assessment but was not documented by the assessor. An audit of new admissions for the last 3 months was conducted by the Executive Director on 2/10/25 to verify that a documented interview was completed. It was found that interviews were being conducted as part of the pre-admission UAI assessment meeting but were not being separately documented. Education was provided to staff completing pre-admission UAIs regarding the requirement for a documented interview that is separate from the UAI assessment by the Executive Director on 2/11/25. Moving forward, the documented interview will be conducted by the Resident Services Coordinator during the pre-admission meeting with the resident. Documentation of this interview will be recorded in the resident’s record. The Executive Director, or her designee, will audit new admission records monthly for the next three months to verify that a documented interview was completed. The results of these audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-325-B
Based on resident record review, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall.
Evidence
  1. Resident 3 (admit date, 08/07/2021) had a fall on 06/06/2024. A fall risk rating was not completed.
  2. Resident 4 (admit date, 07/18/2023) had a fall on 08/21/2024. A fall risk rating was not completed.
  3. Resident 5 (admit date, 02/13/2023) had a fall on 01/11/2024, 04/02/2024, 05/30/2024, 06/12/2024, 08/30/2024, 10/20/2024, 10/21/2024. A fall risk rating was not completed for any of the falls.
Plan of correction
The fall risk ratings were reviewed and updated for Resident #3, Resident #4, and Resident #5 by the AL Manager. An audit of residents who have fallen in the last year was conducted by the Director of Nursing on 1/24/25 and fall risk ratings were reviewed and updated if indicated. Licensed nurses will be re-educated on the requirement to review and update the fall risk rating after a fall by 2/14/25. Moving forward, the Director of Nursing, or her designee, will audit residents who have fallen weekly and update the fall risk rating if indicated. For the next three months, the results of the weekly fall audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
22VAC40-73-310-D
Based on resident record review, the facility failed to ensure that the administrator provided written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission.
Evidence
  1. Resident 7’s (admit date, 09/24/2024) records did not include written assurance.
Plan of correction
Written assurance was provided to Resident #7 by the Sales Counselor at the time of admission but was not properly filed in the resident’s record. The written assurance was located and correctly filed in the resident’s administrative record on 10/31/25. An audit of new admissions for the last 3 months was conducted by the Executive Director on 2/10/25 to verify that the written assurance was completed and properly filed in the resident’s record. No issues were identified. Moving forward, the Resident Services Coordinator, or her designee, will provide written assurance to the resident at the pre-admission meeting and ensure that it is filed in the resident’s record. The Executive Director, or her designee, will audit new admission records monthly for the next three months to verify that written assurance was provided. The results of these audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. If continued non-compliance is observed, additional corrective actions will be implemented.
August 14, 2024Inspection0 violations
Inspection dates
08/14/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
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: 08/14/2024 Time In: 2:22 PM Time Out: 4:22 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/05/2024 regarding allegations in the area(s) of: Personnel, Admission, Retention, and Discharge of Residents, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 130 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 Observations by licensing inspector: LI toured the physical plant of the facility. LI observed residents engaging in a party for a long-term employee’s retirement. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 14, 2024Inspection0 violations
Inspection dates
08/14/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 PERSONNELNone
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/14/2024 Time In: 4:24 PM Time Out: 5:04 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported was received by VDSS Division of Licensing on 06/25/2024 regarding allegations in the area(s) of: allegation of abuse/mistreatment. Number of residents present at the facility at the beginning of the inspection: 130 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI toured the physical plant of the facility. LI observed residents engaging in a party of a long-term employee’s retirement. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 1, 2023Inspection4 violations
Inspection dates
12/01/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 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
22VAC40-73-320-B
Based on record review, the facility failed to ensure that a tuberculosis risk assessment is completed annually for each resident, as
Evidence
  1. d 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
22VAC40-73-680-D
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
  1. 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
22VAC40-73-450-A
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
  1. 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
22VAC40-73-260-A
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
  1. 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
October 17, 2023Inspection0 violations
Inspection dates
10/17/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS
Comments
An announced other inspection was conducted on 10/17/23. 20 rooms were observed and measured. Facility documentation was observed. No violations were cited during the inspection. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 11, 2023Inspection0 violations
Inspection dates
04/11/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 11:10 am on 4/11/2023 and exited at 1:45 pm on 4/11/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The regional licensing office was notified by the facility of plans to make 20 beds currently being used for skilled nursing into beds for ALF residents. LI received a floor plan. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI measured the rooms that are to be used for ALF residents and also inspected the rooms for call bell systems. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 11, 2023Inspection0 violations
Inspection dates
04/11/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED   SERVICES
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: LI entered the facility at 11:10 am on 4/11/2023 and exited at 1:45 pm on 4/11/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 2/17/2023, 2/28/2023, and 4/6/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 20, 2022Inspection2 violations
Inspection dates
12/20/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 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: LI entered the facility at 8:34 am on 12/20/2022 and exited at 3:30 pm on 12/20/2022. 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: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Observations by licensing inspector: LI observed medication administration. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-680-I
Based upon a review of records, the facility failed to ensure that the Medication Administration Record (MAR) includes any medication errors or omissions.
Evidence
  1. On the December 2022 MARS for Resident #6, there are 37 instances in which staff failed to indicate medication omission on the MARS.
Plan of correction
1.Resident #6 was on leave of absence and registered medication aid was trained on documentation omission. 2. A 30-day retrospective review of MARS for medication errors or omissions. 3. Reeducate clinical nurses/supervisors on review of dashboard for documentation completion of orders. Reeducate nurses and registered medication aids on policy for resident who are out of facility. 4. Director of Nursing (DON) or designee will Audit PPC dashboard daily for documentation completion of orders (daily x7, weekly x4, biweekly x4, and monthly x3). Results will be reported at the quarterly QAPI meeting. 5. Team member was coached on 12/29/2022
22VAC40-73-640-A
Plan of correction
1. The order was reviewed with the provider and corrected immediately for Resident #8. 2. A 30- day retrospective review of new/changed orders for accuracy of transcription. 3. Reeducate nurses on policies and process to write and review orders for accuracy upon transcription, 24-hour chart check, and clinical review. 4. Director of Nursing (DON) or designee will perform a daily Audit of all prior day orders for accuracy of transcription (daily x7, weekly x4, biweekly x4, monthly x3). Results will be reported at the quarterly QAPI meetings. 5. The MAR was reviewed, and order corrected on 12/20/2022.
October 18, 2022Inspection1 violation
Inspection dates
10/18/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.
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: LI entered the facility on 10/18/2022 at 8:36 am and exited at 3:20 pm on 10/18/2022. 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: 89 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-320-A
Based upon a review of records, the facility failed to ensure that the physical examination report shall contain the following: A statement that specifies whether the individual is or is not capable of self-administering medication.
Evidence
  1. The physical examination reports found the records for Residents #1, #8, and #9 did not include a statement that the individuals were able or not able to self-administer medications.
Plan of correction
On 10/18/2022 the updated physical examination form was printed which includes medication self-administering criteria-new form placed in admission folders. All old forms have been discarded. Audit completed on 10/27/2022 of all new admission since 8/1/2022-the resident records were updated to include medication self-administering statement for those who do not have medication management performed by facility staff.
July 15, 2022Inspection0 violations
Inspection dates
07/15/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Complete monthly checks of first aid kits to ensure expired items get discarded. To the Residents Rights posting, add the telephone numbers for the State and local Ombudsman as well as the name and telephone number for the regional licensing administrator.
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the building on 7/15/2022 at 9:20am and exited on 7/15/2022 at 11:00am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI inspected emergency equipment and emergency supplies. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.