Above 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 Goodwin House Bailey's Crossroads during CMS and state inspections, most recent first.
A resident with CHF, CKD, and other conditions was not properly monitored for fluid restriction, as required by physician orders. The facility failed to document specific fluid amounts for each shift, and staff interviews revealed a lack of proper monitoring procedures. The facility's policy required accurate fluid intake and output monitoring, which was not followed.
The facility staff failed to maintain kitchen sanitation standards, as observed when employees were seen without hair nets, contrary to policy. Additionally, flowers were improperly stored in the 'dessert' refrigerator. The executive staff acknowledged these issues, and the facility's administration was informed.
A resident was observed self-administering a nebulizer medication without a completed assessment to ensure safety. The facility's policy requires an Interdisciplinary Team assessment and documentation in the EHR before allowing self-administration, but this was not done. A nurse confirmed that a self-assessment form should be completed to determine if residents are alert, oriented, and safe to self-administer medications.
A resident's baseline care plan, which included a fall mat for safety, was not implemented by the facility staff. Despite a physician's order, observations showed the resident in bed without the fall mat, which was found folded against the wall. A nurse confirmed the care plan's purpose is to track treatments and ensure safety, and the need for fall mats is communicated through orders and the CNAs' system. The issue was reported to the administrator and DON.
The facility failed to implement care plans for anticoagulation monitoring for two residents prescribed Eliquis. Despite the requirement to monitor for side effects, no evidence of such monitoring was found. Interviews with residents and an LPN confirmed the lack of documentation and implementation of the care plans, contrary to the facility's policy for comprehensive, person-centered care.
A resident in the facility did not have a physician-ordered fall mat implemented as required. Observations showed the mat was not in place, despite being ordered to prevent fall-related injuries. A nurse confirmed the use of fall mats and the communication process for such interventions, but the facility's policy was not followed, leading to the deficiency.
A resident's incentive spirometer was repeatedly observed uncovered and exposed to air, contrary to facility policy requiring it to be stored in a plastic bag after use. The resident confirmed not being provided a covering, and a nurse acknowledged the need for proper storage to prevent germ exposure.
Two residents in a facility were not adequately monitored for anticoagulation side effects despite being prescribed Eliquis. Both residents had care plans requiring monitoring for signs of hemorrhage and other side effects, but no evidence of such monitoring was found in their medication records. Interviews with the residents and an LPN revealed a lack of documentation and adherence to the facility's anticoagulation protocol.
Failure to Monitor Fluid Restriction for a Resident
Penalty
Summary
The facility staff failed to adequately monitor fluid restriction and intake for Resident #53, who was admitted with diagnoses including toxic hyponatremia, congestive heart failure (CHF), chronic kidney disease (CKD), and atrial fibrillation. The resident was moderately cognitively impaired and dependent on staff for daily activities, including eating. The comprehensive care plan identified a potential for fluid imbalance related to CHF, with interventions to administer medications and assess for edema and abnormal breath sounds. However, the physician's order for a 1500 milliliter daily fluid restriction was not properly documented or monitored, as evidenced by the lack of specific fluid allocation for each shift and dietary department. Interviews with facility staff revealed that there was no specific documentation for fluid restriction amounts, and the resident's water pitcher was removed from the room, with medications given with applesauce. The facility's policy required accurate fluid intake and output monitoring for residents on fluid restriction, but this was not adhered to. The administrative staff acknowledged the deficiency and stated they had begun addressing the issue, but no further information was provided before the survey exit.
Sanitation and Policy Violations in Kitchen
Penalty
Summary
The facility staff failed to maintain the kitchen in a sanitary manner, as observed during a survey. On the morning of August 20, 2024, two employees were seen exiting the kitchen without wearing hair nets, which is against the facility's policy that requires hair coverings to be worn at all times while working in the kitchen. When questioned, the cook and dining services staff acknowledged the requirement and subsequently obtained hair nets. Another dining services staff member entered the dry storage room without a hair net and admitted she should have been wearing one. Additionally, flowers were found stored in the 'dessert' refrigerator, which is not appropriate storage for non-food items. The executive staff member was informed about the flowers in the refrigerator and stated they were temporarily placed there for table vases, but agreed to have them moved. The facility's administrator, director of nursing, and infection prevention nurse were made aware of these findings the following day. The report highlights a failure to adhere to the facility's Dining Services-Personal Appearance and Personal Hygiene policy, which mandates hair coverings in the kitchen, and improper storage practices in the kitchen area.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility staff failed to ensure a resident was safe to self-administer a nebulizer medication. For one resident in the survey sample, the staff did not complete an assessment to determine if the resident was capable of safely self-administering the medication. The resident had a physician's order for ipratropium-albuterol via nebulization for aspiration pneumonia. Despite this, the resident was observed self-administering the nebulizer medication without a completed assessment. An interview with a registered nurse revealed that nurses are responsible for completing a self-assessment form to determine if residents are alert, oriented, and safe to self-administer medications. The facility's policy requires the Interdisciplinary Team to assess and document the safety of self-administration in the Electronic Health Record before allowing residents to self-administer medications. However, no such documentation was presented before the survey exit.
Failure to Implement Baseline Care Plan for Resident Safety
Penalty
Summary
The facility staff failed to implement the baseline care plan for a resident, identified as Resident #169, who was part of a survey sample. The baseline care plan, dated 8/9/24, specified that the resident required a fall mat as a safety measure to ensure their safety during treatments and care. Despite a physician's order for a fall mat dated the same day, observations on 8/20/24 and 8/21/24 revealed that the resident was lying in bed without a fall mat on either side. Instead, the fall mat was found folded up against the wall. An interview with a registered nurse confirmed that the care plan is intended to track treatments and ensure better care, and that the need for fall mats is communicated through physician orders and the CNAs' computer system. The administrative staff, including the administrator and the director of nursing, were informed of the issue, but no further information was provided before the survey exit.
Failure to Implement Anticoagulation Monitoring Care Plans
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for anticoagulation monitoring for two residents, Resident #53 and Resident #319. Resident #53, who was admitted with diagnoses including toxic hyponatremia, CHF, CKD, and atrial fibrillation, was prescribed Eliquis for atrial fibrillation. The care plan required monitoring for signs of hemorrhage and other side effects, but no evidence of such monitoring was found. Interviews with the resident and an LPN revealed that the monitoring was not documented, and the care plan was not implemented. Similarly, Resident #319, admitted with diagnoses including venous thrombosis, hypertension, and gout, was also prescribed Eliquis. The care plan for this resident included similar monitoring requirements for anticoagulation side effects. However, there was no evidence of monitoring, and interviews indicated a lack of documentation and implementation of the care plan. Both residents were moderately cognitively impaired, and the facility's policy required comprehensive, person-centered care plans with measurable objectives, which were not adhered to in these cases.
Failure to Implement Physician-Ordered Fall Intervention
Penalty
Summary
The facility staff failed to implement a physician-ordered fall intervention for a resident, identified as Resident #169, who was part of the survey sample. The clinical record for the resident included a physician's order dated 8/9/24 for a fall mat to be used as a preventive measure. However, during observations on 8/20/24 and 8/21/24, the resident was seen lying in bed without the fall mat in place, which was instead found folded against the wall. An interview with a registered nurse confirmed that fall mats are used in the facility to reduce the impact of falls and that the need for such interventions is communicated through physician orders and the CNAs' computer system. The facility's fall protocol policy emphasizes the importance of providing an environment free from fall hazards and ensuring that interventions are communicated, assigned, documented, and implemented appropriately. Despite this policy, the required intervention was not put into place for the resident.
Improper Storage of Incentive Spirometer
Penalty
Summary
The facility staff failed to provide proper respiratory care for a resident by not storing an incentive spirometer in a sanitary manner. The resident, who was oriented and had a physician's order for using an incentive spirometer three times a day, was observed with the device uncovered and exposed to air on multiple occasions. The resident confirmed that he had not been offered a bag or covering for the spirometer. A registered nurse acknowledged that the spirometer should be stored in a Ziplock bag to prevent exposure to germs. The facility's policy also required the spirometer to be cleaned and stored in a plastic bag after each use, but this was not followed.
Failure to Monitor Anticoagulation Side Effects
Penalty
Summary
The facility staff failed to ensure that two residents, Resident #53 and Resident #319, were free from unnecessary medications by not providing adequate monitoring for anticoagulation side effects. Resident #53, who was admitted with diagnoses including toxic hyponatremia, congestive heart failure, chronic kidney disease, and atrial fibrillation, was prescribed Eliquis for atrial fibrillation. Despite the comprehensive care plan indicating the need to monitor for signs of hemorrhage and other side effects, there was no evidence of such monitoring in the medication administration records for June, July, and August. Interviews with the resident and a licensed practical nurse revealed that monitoring was not documented, and the facility's anticoagulation protocol was not followed. Similarly, Resident #319, admitted with diagnoses including venous thrombosis, hypertension, and gout, was prescribed Eliquis for deep vein thrombosis. The care plan also required monitoring for anticoagulation side effects, but no evidence of monitoring was found in the medication administration records for July and August. An interview with the resident indicated a lack of awareness about monitoring, and a licensed practical nurse confirmed the absence of documentation. The facility's anticoagulation protocol, which mandates monitoring and physician notification in case of side effects, was not adhered to for both residents.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Nursing homes near Falls Church
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carlin Springs Health & Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Goodwin House Alexandria | 1.1 mi | ★★★★★ | 0 | 0 |
| The Jefferson | 2 mi | ★★★★★ | 43 | 3 |
| Alexandria Rehabilitation And Healthcare Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Cherrydale Health & Rehabilitation Center | 3.1 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.