Goodwin House Alexandria

Based on observation, staff interview and facility document review, the facility staff failed to maintain the dumpster area in a clean and sanitary manner for one of one dumpster. The findings include: The facility staff failed to maintain the dumpster area in a clean and sanitary manner. Trash and debris were observed on the ground around the dumpster. On 4/4/23 at 9:45 a.m., observation of the dumpster was conducted with OSM (other staff member) #2, the registered dietitian, and OSM #4, a cook. Trash and debris (including four gloves that were folded inside out, saran wrap, paper debris, an empty specimen cup, a plastic drink cup and a plastic drink cup lid) were observed on the ground around the dumpster. OSM #4 stated the utility department staff goes out to the dumpster to dump trash every hour or so and they should make sure there is not all of that debris around the dumpster. On 4/4/23 at 4:35 p.m., ASM (administrative staff member) #2, the interim administrator, ASM #3, the director of nursing, and OSM (other staff member) #6, the director of dining services, were made aware…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for two of 26 residents in the survey sample, Residents #56 and #28. The findings include: 1. For Resident #56 (R56), the facility staff failed to implement the resident's comprehensive care plan for psychotropic drug use monitoring. R56's comprehensive care plan dated 9/27/22 documented, Psychotropic Drug Use .observe for side effects . A review of R56's clinical record revealed a physician's order dated 11/3/22 for quetiapine (1) 50 mg (milligrams) twice daily. A review of R56's MARs (medication administration records) for January 2023 through April 2023 revealed the resident was administered quetiapine 50 mg twice daily 1/1/23 through 4/2/23. Further review of R56's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for January 2023 through April 2023) failed to reveal the resident was observed for side effects from the medication quetiapine. On 4/4/23 at 3:17 p.m., an interview was conducted with RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications for two of 26 residents in the survey sample, Residents #56 and #28. The findings include: 1. For Resident #56 (R56), the facility staff failed to monitor the resident for side effects from the antipsychotic medication quetiapine (1). A review of R56's clinical record revealed a physician's order dated 11/3/22 for quetiapine 50 mg (milligrams) twice daily. A review of R56's MARs (medication administration records) for January 2023 through April 2023 revealed the resident was administered quetiapine 50 mg twice daily (1/1/23 through 4/2/23). Further review of R56's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for January 2023 through April 2023) failed to reveal the resident was monitored for side effects from the medication quetiapine. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents should be monitored for side…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility document review, the facility staff failed to ensure food items available for use were used or discarded prior to the best when used by date, in one of eight small house kitchens, the occoquan kitchen. The findings include: The facility staff failed to store mayonnaise in a safe manner. Five (12 ounce) bottles of unopened mayonnaise with a manufacturer's best when used by date of 2/12/23 were observed in the occoquan kitchen pantry. On 4/3/23 at 12:12 p.m., observation of the occoquan kitchen was conducted. Five (12 ounce) bottles of unopened mayonnaise with a manufacturer's best when used by date of 2/12/23 were observed available for use, on the shelf, in the pantry. On 4/4/23 at 9:56 a.m., an interview was conducted with OSM (other staff member) #5, the sous chef. OSM #5 stated unopened mayonnaise should be discarded after the best when used by date. OSM #5 stated, I don't want residents to get sick, and the quality has gone down. On 4/4/23 at 4:35 p.m., ASM (administrative staff member) #2, the interim administrator, ASM #3, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review it was determined facility staff failed Store, food in accordance with professional standards for food service safety in one of eight kitchens observed, [NAME] small house kitchen. The facility failed to dispose of plain Greek yogurt with a best by date of 9/19/21 and honey mustard dressing with a use by date of 1/13/21 located on the [NAME] small house kitchen. The findings include: On 10/12/2021 at approximately 1:30 p.m., an observation was made of the [NAME] small house kitchen in the facility. Observation of the French door refrigerator located in the kitchen area revealed an unopened 32 ounce container of plain Greek yogurt. The container was observed to have the manufacturers date documenting Best by 19 [DATE]. Observation of the standing side by side refrigerator/freezer located in the pantry area of the [NAME] small house kitchen revealed a one gallon container of honey mustard dressing approximately one-quarter full. The container was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a safe and sanitary manner, in two of eight facility household kitchens, the Maherrin household kitchen and the Rappahannock household kitchen. 1. a. The facility staff failed to label and store food in a safe and sanitary manner in the Maherrin household kitchen. 1. b. The facility staff failed to hold cold food at a safe temperature in the Maherrin and Rappahannock household kitchens. 2. The facility staff failed to store dishware in a safe and sanitary manner in the Maherrin and Rappahannock household kitchens. The findings include: 1. a. The facility staff failed to label and store food in a safe and sanitary manner in the Maherrin household kitchen. On 1/29/19 at 12:22 p.m., observation of the Maherrin household kitchen was conducted. The following was observed: In the refrigerator: - An opened glass jar of homemade apricot pineapple jam that documented a resident's name on the top label. The top label documented, Apricot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to serve food in a manner to promote dignity for one of 31 residents in the survey sample, Resident # 37. During a dining observation, in the [NAME] household unit dining room, Resident # 37 was observed sitting at the dining room table and waiting 23 minutes to be served and assisted with eating his meal by staff, while watching seven residents seated at the table with him, eat their dinner. The findings include: Resident # 37 was admitted to the facility on [DATE] and a readmission on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease (1), dysphagia (2), atrial fibrillation (3) and chronic respiratory failure (4). Resident # 37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/04/18, coded Resident # 37 as scoring a 3 (three) on the brief interview for mental status (BIMS) of a score of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to meet the appropriate transfer requirements for three of 31 residents in the survey sample; Resident # 46, # 21, and # 69. 1. The facility staff failed to evidence that Resident #46's comprehensive care plan goals were sent with the resident to the hospital for the facility initiated transfer dated 01/06/2019. 2. The facility staff failed to evidence that Resident # 21's comprehensive care plan goals were sent with the resident to the hospital for facility initiated transfer dated 01/07/2019. 3. The facility staff failed to provide the receiving facility with the Resident #69's comprehensive care plan goals for a facility initiated transfer to hospital that occurred on 12/11/18. The findings include: 1. The facility staff failed to evidence that Resident #46's comprehensive care plan goals were sent with the resident to the hospital for the facility initiated transfer dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, it was determined that the facility staff failed to complete a discharge minimum data set (MDS) assessment for one of 31 residents in the survey sample; Resident #2. Resident #2 expired in the facility on [DATE]. The most recent MDS in the facility's system was a quarterly MDS with an ARD (assessment reference date) of [DATE]. As of [DATE], the date of the survey, there had been no discharge MDS assessment completed. The findings include: Resident #2 was admitted to the facility on [DATE] with the diagnoses of but not limited to high blood pressure, hypothyroidism, heart disease, chronic kidney disease, and Rheumatoid Arthritis. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of [DATE]. The resident was coded as mildly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for transfers, dressing, and toileting; limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure the comprehensive care plan was implemented for two of 31 residents in the survey sample, Resident # 72 and Resident #70. 1. During multiple observations, Resident #72 was receiving oxygen at 2 (two) and a half, liters instead of the 2 L (two liters) ordered by the physician and per the residents comprehensive care plan. 2. The facility staff failed to implement Resident #70's comprehensive care plan to offer non-pharmacological pain relief methods as needed and prior to the administering as needed pain medication to Resident #70. The findings include: 1. Resident # 72 was admitted to the facility on [DATE] with a readmission [DATE] with diagnoses, which included but were not limited to: heart failure (1), atrial fibrillation (2), dysphagia (3) and pleural effusion (4). Resident # 72's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure respiratory care and services were provided in accordance with professional standard of practice and the comprehensive person-centered care plan for one of 31 residents in the survey sample, Resident # 72. The facility staff failed to administer Resident # 72's oxygen according to the physician's orders. The findings include: Resident # 72 was admitted to the facility on [DATE] with a readmission [DATE] with diagnoses that included but were not limited to: heart failure (1), atrial fibrillation (2), dysphagia (3) and pleural effusion (4). Resident # 72's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/18, coded Resident # 72 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Resident # 72 was coded as requiring limited to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that facility staff failed to provide pain management for two of 31 residents in the survey sample, Residents # 46 and # 70. 1. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #46. 2. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #70. The findings include: 1. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #46. Resident # 46 was admitted to the facility on [DATE] with a readmission of 01/09/19 with diagnoses that included but were not limited to pain, hemiplegia (1), type 2 (two) diabetes (2), dementia (3) gastroesophageal reflux disease (4), and hypertension (5). Resident # 46's most recent MDS (minimum data set), 5 (five)-day assessment with an ARD (assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for three of 31 residents in the survey sample, Residents #223, #127 and #68. 1. The facility staff failed to document non-pharmacological interventions that were offered to Resident #223 prior to administering as needed pain medication to the resident on multiple dates in January 2019. 2. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #127, on 8 occasions in January 2019. 3. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #68, on 10 occasions in January 2019. The findings include: 1. The facility staff failed to document non-pharmacological interventions that were offered to Resident #223 prior to administering as needed pain medication to the resident on multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility staff failed to serve food in a sanitary manner in two of eight resident dining rooms. 1. CNA (Certified nursing assistant) # 3 failed to change gloves in between touching cabinet and drawer handles, oven door handle and the food contact areas of serving platters, casserole dish and dinner plates that was used to serve food in the [NAME] household unit. 2. CNA (Certified nursing assistant) #1 failed to change gloves in between touching cabinet handles and the food contact areas of a bowl and a plate that was used to serve food in the Maherrin household unit. The findings include: 1. CNA (Certified nursing assistant) # 3 failed to change gloves in between touching cabinet and drawer handles, oven door handle and the food contact areas of serving platters, casserole dish and dinner plates that was used to serve food in the [NAME] household unit. On 1/29/19 at 5:06 p.m., an observation of the evening meal was conducted on the [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.