The View Alexandria by Goodwin Living

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.

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.

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.

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.

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

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.

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.

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.?

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.?

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.

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: Resident 7?s (admit date, 09/24/2024) records did not include written assurance.

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.

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.

Based on resident record review, the facility failed to ensure that the individualized service plan ( ISP

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.

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.

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.

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

Based on resident record review and staff interview, the facility failed to ensure that the medications ordered for PRN

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.

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.

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.

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.?

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. 5. On 10/23/2024, LI interviewed Staff 7 who confirmed that residents did not sign and date the emergency preparedness and response plan review. 6. 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.

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.

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.

Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Evidence: No documentation was provided, during the inspection, to confirm that Staff #1 (hired 8/21/14) has current first aid certification. Staff #1's record contained current certification for CPR and AED, but not first aid.

Based on record review, the facility failed to ensure that a tuberculosis risk assessment is completed annually for each resident, as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Residents #2, #4, and #5 contained tuberculosis screening and risk assessment forms, from November 2023. The results section was not completed on the tuberculosis risk assessment forms for Residents #2, #4, and #5.

Based on record review, the facility failed to ensure that a preliminary plan of care is developed, on or within seven days prior to the day a resident's admission. The preliminary plan shall be identified as such and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #8's record states that she was admitted on 10/25/23. Resident #8's individualized service plan ( ISP

Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician's order and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Medication administration for Resident #1 was observed during the inspection. Resident #1's medication administration record ( MAR