Inspection Report
Renewal
Census: 128
Deficiencies: 19
Oct 23, 2024
Visit Reason
The inspection was a renewal inspection conducted on October 23 and 24, 2024, to assess compliance with applicable standards and regulations for The View Alexandria by Goodwin Living assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including deficiencies in volunteer orientation, staffing plan, admission documentation, medication management, resident care plans, emergency preparedness, resident council responses, facility maintenance, and confidentiality of resident records. Plans of correction were provided for each deficiency.
Deficiencies (19)
| Description |
|---|
| Facility failed to ensure all volunteers attended orientation prior to service. |
| Facility failed to maintain a written staffing plan related to resident acuity and care needs. |
| Facility admitted a resident without documented interview to ensure needs could be met. |
| Facility failed to provide written assurance of appropriate license to resident at admission. |
| Physical examination for admission was not completed within 30 days or was incomplete. |
| Fall risk ratings were not reviewed or updated after resident falls. |
| Individualized service plan was not reviewed and updated to reflect current resident needs. |
| Medications and supplements were not filled and refilled timely to avoid missed dosages. |
| Resident's physician orders were unsigned or incomplete in the record. |
| Medications were not stored securely; medication cart was left open during pass. |
| Medications were administered outside the facility's standard dosing schedule without proper documentation. |
| PRN medications were not available or properly labeled for residents. |
| Facility failed to provide written responses to resident council recommendations prior to next meeting. |
| Facility failed to maintain buildings and grounds in good repair and free of rubbish. |
| Emergency preparedness plan lacked documentation of initial and annual contact with local emergency coordinator. |
| Emergency preparedness plan lacked description of generator capacity. |
| Facility failed to implement orientation and semi-annual review of emergency preparedness plan for residents and volunteers. |
| Staff did not participate in resident emergency drills on all shifts every six months. |
| Resident's personal affairs and records were not afforded confidential treatment during medication administration. |
Report Facts
Number of residents present: 128
Number of resident records reviewed: 8
Number of staff records reviewed: 6
Number of resident interviews conducted: 2
Number of staff interviews conducted: 2
Dates of resident council meetings without written responses: 11
Number of staff participating in emergency drills vs. staff on duty: 13
Number of staff signed in for choking drill vs. staff on duty: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and interviews |
| Staff 7 | New administrator involved in admission documentation and emergency preparedness plan | |
| Staff 8 | Interviewed regarding staffing plan and unsigned physician orders | |
| Staff 10 | Interviewed regarding volunteer orientation and emergency preparedness training | |
| Staff 13 | Observed administering medication and medication storage issues | |
| Staff 14 | Confirmed medication availability issues | |
| Executive Director | Developed staffing plan, conducted audits, and provided corrective actions | |
| Director of Nursing | Provided education, conducted audits, and oversaw medication and care plan compliance | |
| AL Manager | Conducted medication cart observations and audits | |
| Life Enrichment Director | Maintains volunteer training schedule and emergency preparedness education | |
| Resident Services Coordinator | Responsible for admission interviews, written assurances, and emergency preparedness reviews | |
| Director of Facilities | Revised emergency drill schedule and conducted environmental rounds |
Inspection Report
Census: 130
Deficiencies: 0
Aug 14, 2024
Visit Reason
The inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations of abuse/mistreatment. The visit included a tour of the physical plant and review of records.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were explicitly stated.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 130
Deficiencies: 0
Aug 14, 2024
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2024-08-05 regarding allegations in the areas of Personnel, Admission, Retention, and Discharge of Residents, and Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector toured the physical plant and observed residents engaging in a party for a long-term employee's retirement.
Report Facts
Number of residents present: 130
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
Inspection Report
Renewal
Census: 116
Deficiencies: 4
Dec 1, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure direct care staff maintain current first aid certification, incomplete tuberculosis risk assessments for residents, lack of signed preliminary plans of care for new residents, and medication administration not consistent with physician orders.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that each direct care staff member maintains current certification in first aid. |
| Facility failed to ensure that a tuberculosis risk assessment is completed annually for each resident with all required sections completed. |
| Facility failed to ensure that a preliminary plan of care is developed and signed by the resident or legal representative within seven days prior to admission. |
| Facility failed to ensure medications are administered in accordance with physician's orders; Resident #1 did not receive Tacrolimus as ordered. |
Report Facts
Number of resident records reviewed: 10
Number of resident interviews conducted: 5
Number of staff interviews conducted: 2
Inspection Report
Deficiencies: 0
Oct 17, 2023
Visit Reason
An announced other inspection was conducted to observe and measure 20 rooms and review facility documentation.
Findings
No violations were cited during the inspection.
Report Facts
Rooms observed: 20
Inspection Report
Monitoring
Deficiencies: 0
Apr 11, 2023
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care and related services, following self-reports received regarding allegations in these areas.
Findings
The investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found during the inspection.
Report Facts
Resident records reviewed: 3
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Inspection Report
Deficiencies: 0
Apr 11, 2023
Visit Reason
The inspection was conducted as a type 'Other' inspection to review the physical plant and building grounds, including plans to convert 20 beds from skilled nursing to assisted living facility residents.
Findings
The licensing inspector toured the facility, measured rooms intended for assisted living residents, and inspected call bell systems. No resident or staff records or interviews were conducted during this inspection.
Report Facts
Beds planned for conversion: 20
Inspection Report
Renewal
Census: 85
Deficiencies: 2
Dec 20, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license, with the licensing inspector on-site to assess compliance with applicable standards and regulations.
Findings
The inspection found non-compliance with applicable standards or laws, specifically related to medication administration and documentation errors, which were documented in violation notices issued to the facility.
Deficiencies (2)
| Description |
|---|
| The order was reviewed with the provider and corrected immediately for Resident #8. A 30-day retrospective review of new/changed orders for accuracy of transcription was required. Nurses were reeducated on policies and processes to write and review orders for accuracy upon transcription, 24-hour chart check, and clinical review. The Director of Nursing or designee will perform daily audits of prior day orders for accuracy of transcription with results reported at quarterly QAPI meetings. The MAR was reviewed and order corrected on 12/20/2022. |
| The facility failed to ensure that the Medication Administration Record (MAR) includes any medication errors or omissions. Specifically, on the December 2022 MARs for Resident #6, there were 37 instances where staff failed to indicate medication omission on the MARs. A 30-day retrospective review of MARs for medication errors or omissions was required. Clinical nurses and supervisors were reeducated on review of dashboard for documentation completion of orders. Nurses and registered medication aids were reeducated on policy for residents who are out of the facility. The Director of Nursing or designee will audit the PPC dashboard daily for documentation completion of orders with results reported at quarterly QAPI meetings. A team member was coached on 12/29/2022. |
Report Facts
Residents present: 85
Resident records reviewed: 10
Staff records reviewed: 5
Medication omission instances: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Eddy | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Nina Wilson | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 89
Deficiencies: 1
Oct 18, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to physical examination reports lacking statements on residents' capability to self-administer medication. A violation notice was issued and the facility was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that physical examination reports contained a statement specifying whether the individual is capable of self-administering medication. |
Report Facts
Number of residents present: 89
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews conducted: 2
Number of staff interviews conducted: 0
Inspection Report
Original Licensing
Deficiencies: 0
Jul 15, 2022
Visit Reason
Initial licensing inspection to evaluate the facility for issuance of a license to operate.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed staff records with no deficiencies noted.
Report Facts
Number of staff records reviewed: 3
Number of resident records reviewed: 0
Number of interviews conducted with staff: 3
Number of interviews conducted with residents: 0
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