3 Reports · 1 Summary
Inspection Summary
7 inspections covered, May 2021 – Jan 2026.
Inspection Reports Summary
Visit Reason
This report covers 7 inspections of Goodwin House Alexandria from May 10, 2021 to January 23, 2026, including one complaint survey.
Complaint Details
A complaint was received by VDSS on 11/26/2025 regarding staffing, resident care, and complaint investigation. The investigation found no evidence to support the allegations and no violations were cited on 01/23/2026.
Findings
Across that history VDSS cited 5 violations under 5 distinct standards. Three visits ended with violations cited and four with none.
Violations (5)
22VAC40-73-1110-A: Failed to ensure determination of appropriate placement in special care unit for resident with dementia.
22VAC40-73-260-A: Failed to ensure direct care staff maintain current first aid certification.
22VAC40-73-1090-A: Failed to ensure resident assessed by licensed professional for serious cognitive impairment prior to admission.
22VAC40-73-660-B: Failed to ensure medication storage limited to out-of-sight place for residents capable of self-administering medication.
22VAC40-73-680-M: Failed to ensure PRN medications are available and properly stored at the facility.
Report Facts
Violations cited: 5
Distinct standards: 5
Inspections on page: 7
Inspections with violations: 3
Complaint visits: 1
Individual Reports
One document per inspection visit.
Inspection Report — Apr 5, 2023
Routine
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.
Violations (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 — Oct 12, 2021
Routine
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.
Violations (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 — Jan 31, 2019
Annual Inspection
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.
Violations (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 |
3 CMS Surveys
CMS Survey — Jan 31, 2019
Jan 31, 2019
CMS Survey — Oct 14, 2021
Oct 14, 2021
CMS Survey — Apr 5, 2023
Apr 5, 2023
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