Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at George Washington Health & Rehabilitation during CMS and state inspections, most recent first.
Two residents in a facility did not receive timely and appropriate care for pressure injuries, with delays in treatment and inconsistent documentation of skin assessments. Physician orders were not followed promptly, and treatment records lacked evidence of care being administered. Interviews revealed non-compliance with facility policies on pressure injury management.
The facility staff failed to implement proper infection control practices during wound care for a resident, as an LPN did not change gloves between treating multiple wounds. Additionally, the facility lacked evidence of an infection control surveillance program before June 2024. Staff also did not adhere to PPE and hand hygiene protocols in a Transmission-Based Precaution room for another resident, with staff members not wearing full PPE and failing to perform hand hygiene.
A resident's dignity was compromised during a dressing change when an LPN wrote on the dressing while it was on the resident. The facility's policy requires labeling before application to maintain dignity. Interviews confirmed the dignity concern, and the incident was reported to administrative staff.
The facility staff failed to implement comprehensive care plans for two residents, leading to deficiencies in the treatment of pressure injuries and infection precautions. One resident did not receive documented wound care for several days, while another's treatment records showed no evidence of required care over two months. Additionally, staff did not follow transmission-based precautions, failing to wear full PPE during care. Interviews confirmed the care plans were not adhered to, despite their importance in guiding resident care.
A resident experienced a fall resulting in a forehead hematoma and was transferred to the ER. Despite this incident, the facility staff did not review or revise the resident's care plan to include new interventions to prevent future falls. Interviews with staff confirmed the oversight, which was contrary to the facility's policy requiring updates after significant changes in a resident's condition.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility staff failed to provide timely and appropriate care for pressure injuries for two residents, leading to deficiencies in their treatment. For one resident, the staff did not implement treatments for four pressure injuries upon admission, delaying care from the admission date until three days later. The physician orders for treatment were not documented until after this delay, and there was no evidence of wound care being provided during this period. Additionally, the facility staff failed to accurately document skin assessments, with inconsistencies noted in the weekly skin observation records. For another resident, the facility staff did not document the treatment of pressure injuries over a two-month period, despite physician orders being in place. The treatment administration records did not show evidence of the prescribed treatments being completed. Although the wound care physician's notes indicated healing, the lack of documentation suggests a failure in following through with the treatment plan. Furthermore, the skin assessments for this resident were inconsistently documented, with discrepancies in the records regarding the presence of wounds and ongoing treatment. Interviews with facility staff revealed a lack of adherence to the facility's policy on pressure injury prevention and management, which requires prompt reporting of changes in skin integrity and weekly skin observations. The administrative staff were made aware of these findings, but no further information was provided before the surveyors exited the facility.
Infection Control Deficiencies in Wound Care and PPE Use
Penalty
Summary
The facility staff failed to implement proper infection control practices during wound care for Resident #6. An LPN was observed performing wound care on multiple wounds of the resident without changing gloves between each wound, which is against the facility's policy for clean dressing. The LPN admitted that each wound should be treated separately, but during the observation, she did not follow this protocol, leading to potential cross-contamination between the wounds. The facility also failed to provide evidence of an infection control surveillance program prior to June 2024. During an interview, an administrative staff member stated that the facility had only started tracking infection control on Point Click Care from June 2024 onwards, and no evidence could be produced for infection tracking before this date. This lack of documentation indicates a gap in the facility's infection prevention and control program. Additionally, the facility staff did not adhere to proper PPE and hand hygiene protocols in a Transmission-Based Precaution room for Resident #3. Staff members were observed not wearing full PPE while performing incontinence care, despite a sign indicating Enhanced Barrier Precautions. Furthermore, a CNA exited the resident's room without performing hand hygiene. Interviews with the staff confirmed the importance of PPE and hand hygiene, but the staff admitted to not following these protocols due to being in a rush.
Failure to Maintain Resident Dignity During Dressing Change
Penalty
Summary
The facility staff failed to maintain the dignity of a resident during a dressing change procedure. During an observation, an LPN was seen performing wound care on a resident's left hip wound. After applying the dressing, the LPN wrote the date and her initials directly on the dressing while it was on the resident. This action was identified as a failure to maintain the resident's dignity. Interviews with the LPN and the Director of Nursing revealed uncertainty and acknowledgment of the dignity concern. The facility's policy on dignity emphasizes treating residents with respect and ensuring their well-being and self-esteem. Additionally, the facility's policy on clean dressing specifies that the date and initials should be labeled on the dressing before it is placed on the resident. The incident was reported to the facility's administrative staff, including the administrator and the regional director of clinical operations.
Failure to Implement Comprehensive Care Plans for Pressure Injuries and Infection Precautions
Penalty
Summary
The facility staff failed to implement comprehensive care plans for two residents, leading to deficiencies in the treatment of pressure injuries. For Resident #3, the care plan documented the need for specific wound treatments, but there was no evidence of treatment from 6/11/24 to 6/13/24. Physician orders for wound care were not documented until 6/14/24, indicating a delay in treatment. Interviews with staff revealed a lack of adherence to the care plan, with LPN #1 acknowledging the importance of following the care plan but failing to do so. Similarly, for Resident #6, the facility staff did not implement the care plan for pressure injuries. The care plan required specific treatments for wounds, but the treatment administration record from June to August 2024 showed no documentation of these treatments being completed. Interviews with staff confirmed that the care plan was not followed, and the administrator, director of nursing, and regional director of clinical operations were made aware of these findings. Additionally, the facility staff failed to follow the comprehensive care plan regarding transmission-based precautions for Resident #3. Staff members were observed not wearing full personal protective equipment (PPE) while providing care, despite the resident being on enhanced barrier precautions. The care plan required maintaining universal precautions, but staff admitted to not following these due to being in a rush. The facility's policy emphasized the importance of developing and implementing a comprehensive person-centered care plan, but this was not adhered to in these cases.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for a resident after a fall incident on 8/1/23. The resident was found lying supine in bed with a left forehead hematoma and was unable to communicate pain levels. The medical doctor was contacted, and the resident was transferred to the emergency room for further evaluation. Despite this significant event, the care plan, which was last updated on 7/19/23, was not reviewed or revised to include new interventions to prevent future falls. Interviews with facility staff, including the regional director of clinical operations and an LPN, confirmed that the care plan was not updated following the fall. The facility's policy requires the care plan to be reviewed and updated when there is a significant change in the resident's condition, which did not occur in this case. The deficiency was acknowledged by the facility's administrator, director of nursing, and regional director of clinical operations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Vernon Healthcare Center | 1.1 mi | ★★★★★ | 18 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 3.8 mi | ★★★★★ | 35 | 0 |
| Woodbine Rehabilitation & Healthcare Center | 5.7 mi | ★★★★★ | 0 | 0 |
| Alexandria Rehabilitation And Healthcare Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Harborside Health & Rehabilitation | 6.7 mi | ★★★★★ | 10 | 1 |
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