Deficiencies (last 6 years)
Deficiencies (over 6 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
56 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 56
Deficiencies: 1
Date: Aug 18, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and regulations at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to the admission of a resident with serious cognitive impairment without proper documentation of placement determination in the special care unit. A violation notice was issued and the facility was given the opportunity to submit a plan of correction.
Deficiencies (1)
The facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit is appropriate.
Report Facts
Number of residents present: 56
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews: 1
Number of staff interviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Renewal
Census: 55
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
The inspection was conducted as a renewal inspection to evaluate compliance with applicable standards and licensing requirements.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector toured the physical plant and observed residents engaged in various activities without identifying any deficiencies.
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 206
Deficiencies: 1
Date: May 10, 2023
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance related to staff certification requirements, specifically that two staff members did not have current first aid certification as required.
Deficiencies (1)
Facility failed to ensure that each direct care staff member maintains current certification in first aid from approved organizations.
Report Facts
Residents in care: 206
Resident records reviewed: 10
Staff records reviewed: 4
Inspection Report
Routine
Deficiencies: 4
Date: Apr 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication monitoring, food safety, and sanitation at Goodwin House Alexandria nursing home.
Findings
The facility failed to implement comprehensive care plans for psychotropic drug use monitoring for two residents, failed to monitor side effects of psychotropic medications, failed to discard expired food items, and failed to maintain the dumpster area in a clean and sanitary manner.
Deficiencies (4)
Failed to implement the comprehensive care plan for psychotropic drug use monitoring for Residents #56 and #28.
Failed to ensure residents were free from unnecessary psychotropic medications and failed to monitor for side effects for Residents #56 and #28.
Failed to ensure food items were used or discarded prior to the best when used by date; specifically, unopened mayonnaise bottles expired on 2/12/23 were found in the kitchen pantry.
Failed to maintain the dumpster area in a clean and sanitary manner; trash and debris were observed on the ground around the dumpster.
Report Facts
Residents in survey sample: 26
Expired mayonnaise bottles: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding comprehensive care plans and psychotropic medication monitoring |
| ASM #2 | Interim Administrator | Made aware of concerns regarding care plan implementation, medication monitoring, food safety, and sanitation |
| ASM #3 | Interim Director of Nursing | Made aware of concerns regarding care plan implementation, medication monitoring, food safety, and sanitation |
| OSM #5 | Sous Chef | Interviewed regarding food safety and expiration of mayonnaise |
| OSM #6 | Director of Dining Services | Made aware of food safety and sanitation concerns |
| OSM #2 | Registered Dietitian | Observed dumpster area with trash and debris |
| OSM #4 | Cook | Observed dumpster area with trash and debris |
Inspection Report
Monitoring
Deficiencies: 0
Date: Aug 23, 2022
Visit Reason
An unannounced focused monitoring inspection was conducted on 8/23/22 to follow-up on high-risk violations that were cited on 6/9/22.
Findings
Building and grounds were inspected and resident records were observed. No violations were cited during the inspection.
Inspection Report
Monitoring
Census: 49
Deficiencies: 3
Date: Jun 9, 2022
Visit Reason
An unannounced monitoring inspection was conducted to review meals, medication administration, activities, building and grounds, records, and interviews.
Findings
The inspection identified violations related to assessment of serious cognitive impairment, medication storage, and availability of PRN medications. Plans of correction were requested for each violation.
Deficiencies (3)
Facility failed to ensure that each resident is assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission to the safe, secure environment.
Facility failed to ensure medication storage is limited to an out-of-sight place in rooms of residents capable of self-administering medication.
Facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility.
Report Facts
Residents in care: 49
Resident records reviewed: 8
Staff records reviewed: 4
Individual interviews conducted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Inspector | Current inspector conducting the inspection |
| Assisted Living Administrator | Responsible person for plan of correction related to cognitive impairment assessment and medication storage | |
| Assisted Living Charge Nurse | Responsible person for plan of correction related to PRN medication availability and storage |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 12, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service safety standards, specifically regarding the proper storage and disposal of food items in the kitchen.
Findings
The facility failed to dispose of expired food items, including plain Greek yogurt past its best by date and honey mustard dressing past its use by date, in one of eight kitchens observed. Interviews with staff confirmed lapses in checking and discarding expired food items despite established policies.
Deficiencies (1)
Failure 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 in the small house kitchen.
Report Facts
Date of expired plain Greek yogurt: Sep 19, 2021
Date of expired honey mustard dressing: Jan 13, 2021
Inspection date: Oct 12, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant/Care Partner | Interviewed regarding food storage and expiration checks in the small house kitchen |
| OSM #1 | Executive Chef | Interviewed about manufacturer guidelines and facility policies on food storage |
| OSM #2 | Director of Dining | Interviewed about kitchen checks and labeling system for food items |
| ASM #1 | Administrator | Made aware of findings |
| ASM #2 | Director of Nursing | Made aware of findings and provided facility policy on food storage |
Inspection Report
Routine
Census: 49
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The inspection was initiated as a routine visit to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations with applicable standards or law. No deficiencies were issued during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 31, 2019
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements, including resident rights, transfer procedures, care plan implementation, pain management, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to serve food with dignity, failure to provide comprehensive care plan goals during hospital transfers, incomplete MDS assessments, failure to implement care plans for oxygen therapy and pain management, unsafe food storage and handling practices, and inadequate documentation of non-pharmacological pain interventions.
Deficiencies (8)
Facility staff failed to serve food in a manner to promote dignity for Resident #37, who waited 23 minutes to be served while others ate.
Facility staff failed to provide receiving hospitals with comprehensive care plan goals for Residents #46, #21, and #69 during transfers.
Facility staff failed to complete a discharge MDS assessment for Resident #2 after death in the facility.
Facility staff failed to administer oxygen to Resident #72 according to physician's orders, delivering 2.5 liters instead of 2 liters.
Facility staff failed to implement comprehensive care plans for Residents #70 and #72, including failure to offer non-pharmacological pain relief methods prior to administering pain medication.
Facility staff failed to store, prepare, and serve food in a safe and sanitary manner in the Maherrin and Rappahannock household kitchens, including unlabeled food, improper cold food holding temperatures, and improper storage of dishware.
Facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Residents #127, #68, and #223 on multiple occasions.
Facility staff failed to serve food in a sanitary manner in two resident dining rooms, including failure to change gloves between touching non-food surfaces and food contact surfaces.
Report Facts
Residents in survey sample: 31
Residents affected by deficiencies: 2
Residents affected by deficiencies: 4
Residents affected by deficiencies: 3
Residents affected by deficiencies: 1
Minutes Resident #37 waited to be served: 23
Cold food holding temperature: 50
Cold food holding temperature: 53
Pain medication administration dates: 14
Pain medication administration dates: 8
Pain medication administration dates: 10
Pain medication administration dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in finding for failing to change gloves between touching non-food and food contact surfaces during meal service |
| CNA #1 | Certified Nursing Assistant | Named in finding for failing to change gloves between touching cabinet handles and food contact surfaces |
| ASM #1 | Administrator | Made aware of multiple findings including food safety and infection control |
| ASM #2 | Director of Clinical Services | Made aware of multiple findings including care plan implementation, pain management, and food safety |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding oxygen concentrator flow rate and physician orders |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding pain assessment and non-pharmacological interventions |
| RN #3 | Registered Nurse | Interviewed regarding pain management and documentation for Resident #127 |
| RN #2 | Registered Nurse | Interviewed regarding pain management and documentation for Resident #68 |
| RN #1 | Registered Nurse | Interviewed regarding pain medication administration and non-pharmacological interventions |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding pain medication administration and non-pharmacological interventions |
| RN #4 | Registered Nurse, MDS Coordinator | Interviewed regarding failure to complete discharge MDS assessment |
Viewing
Loading inspection reports...
