Loudoun Rehabilitation and Nursing Center

Inspectors wrote2.a. For Resident #15 (R15), the facility staff failed to assess the resident to determine if the resident could safely spend time unsupervised on the courtyard patio and failed to provide supervision and a safe environment on the courtyard patio. R15 was unsupervised and fell on the courtyard patio. The resident sustained a head injury that required hospitalization, two staples for a laceration, and a C2 (second cervical) vertebral fracture. R15's diagnoses included but were not limited to congestive heart failure, muscle wasting and atrophy, paranoid personality disorder, auditory hallucinations, and dementia. R15's comprehensive care plan dated 7/19/23 failed to document information regarding the resident spending time outside on the courtyard patio. A review of R15's clinical record revealed the resident sustained falls on 1/9/25, 2/25/25, 3/23/25, and 3/27/25. [...]

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure effective communication training was completed for five of five direct care staff employee reviews.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that facility staff failed to notify the physician and responsible party as required for three of 31 current residents in the survey sample, Residents #1 (R1), R24 and R29.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to obtain criminal background checks to screen for abuse of six of six contract employees.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that facility staff failed to follow the physician's order for two of 31 current residents in the survey sample, Residents #1 (R1) and R2.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to complete an annual performance review for three of five CNA (certified nursing assistant) reviews.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility staff failed to transport resident personal laundry in a sanitary manner on one of two floors, second floor.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure behavioral health training was completed for four of five employee reviews.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that facility staff failed to promote resident's dignity for two of 31 current residents in the survey sample, Residents #1 (R1) and R7.

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to keep residents free from neglect for two of 31 residents in the survey sample, Residents #13 (R13) and R19.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to implement the abuse policy for of six of six contract employees and failed to investigate and report allegations of abuse and exploitation for one of 31 residents in the survey sample, Resident #18 (R18).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to report an allegation of resident exploitation to the State Agency (SA) for one of 31 residents in the survey sample, Resident #28.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to investigate an allegation of resident exploitation for one of 31 residents in the survey sample, Resident #28.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide a safe discharge for one of 31 residents in the survey sample, Resident #28.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide required documentation for discharge for one of 31 residents in the survey sample, Resident #28.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 31 residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to revise the comprehensive care plan for one of 31 residents in the survey sample, Residents #1 (R1). For R1, facility staff failed to revise the comprehensive care plan for the discontinued use of a voice amplifier. R1 was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. The physician's order for R1 documented in part, SPECIAL EQUIPMENT: Voice amplifier and charger will be stored at bedside per resident request. [...]

Inspectors wrote2. For R1, the facility staff failed to provide a scheduled bath. R1 was admitted with diagnoses that included but were not limited to hemiplegia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section GG 0130 Self Care coded R1 as being dependent for showers or bathing self. The facility's POC (point of care) sheet for R1 dated May 2025 documented, in part, Shower Schedule: Wed/Sat Eve (Wednesday/Saturday Evening) shift. Review of the POC revealed a a blank on 05/07/2025 for showers. The comprehensive care plan for R1 with a revision date 01/25/2024 documented in part, Focus. [...]

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to provide incontinence care for two of 31 residents in the survey sample, Residents #13 (R13) and R19.

Inspectors wrote2. For R1, the facility staff failed to store a nebulizer (1) mask in a sanitary manner. R1 was admitted to the facility with diagnoses that included but were not limited to pneumonia. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. On 05/14/2024 at approximately 2:00 p.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. On 05/14/2024 at approximately 5:00 p.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. On 05/15/2024 at approximately 9:40 a.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. [...]

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to care for a resident's needs for one of 31 residents in the survey sample, Resident #1 (R1).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 31 residents in the survey sample, Resident #28.

Inspectors wroteBased on observation, family interview, staff interview and facility document review, it was determined the facility staff failed to discard biologicals past their expiration date in one of two nursing unit storage closets and one of one central supply storage areas.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to serve pureed food in a form to meet the needs of residents in one of one kitchen.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to report a fire that occurred at the facility on 12/21/2024 to the state agency as required in 12VAC5-371-190.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to maintain an accurate clinical record for one of 31 residents in the survey sample, Resident #28.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure training regarding the facility QAPI (quality assurance and performance improvement) program was completed for two of five employee reviews.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure CNAs (certified nursing assistants) completed required annual in-service trainings for two of five CNA reviews.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to administer an antibiotic for the treatment of a urinary tract infection. The resident missed six prescribed doses of Macrobid. The resident was sent out to the hospital three days later and admitted with septic shock from E. coli bacteremia/E.coli urinary tract infection, thus causing harm to one of two residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for one of two residents in the survey sample, Resident #1.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to prepare and serve food and liquids to residents with orders for modified consistency diets for two of 41 residents in the survey sample, Residents #80 and #8. For Resident #8, the facility staff failed to serve pureed foods as ordered by the physician. For Resident #80, the facility staff served the incorrect food and fluid consistency which resulted in Resident #80 coughing and a nosebleed. The facility's deficient practice placed the resident at risk of infection, lack of oxygen to the brain, or death. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity was lowered to a level 2 isolated.

Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, the facility staff failed failed to maintain an effective infection control tracking system; failed to maintain an effective infection control program for five of 41 residents in the survey sample, Residents #49 #24, #15, #86, #76 ; and failed to store linens in a sanitary manner, for one of one linen carts.

Inspectors wroteBased on observations, staff interview, resident interview, and facility document review, it was determined the facility staff failed to develop/implement the care plan for three of 41 residents in the survey sample; Resident #8, Resident #5 and Resident #63.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to provide evidence of providing ADL (activities of daily living) care for one of 41 dependent residents, Resident #146.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to prepare, store, and serve food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on observation, staff interview, facility document review, it was determined the facility staff failed to conduct regular bed inspections for four of 41 residents in the survey sample, Residents #63, #48, #9 and #7.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain dignity for three of 41 residents in the survey sample, Residents #246, #42, and #24.

Inspectors wroteBased on observation, resident interview, staff interview and facility document review, it was determined the facility staff failed to assess a resident for the self-administration of a medicated mouthwash for one of 41 residents in the survey sample, Resident #45.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to implement Advance Directive requirements for one of 41 residents in the survey sample, Resident #6.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to issue a beneficiary notice of non-coverage for one of three beneficiary notice reviews, Resident #75.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to protect clinical information privacy for one of 41 residents in the survey sample, Resident #246.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to provide a clean, homelike environment for one of 41 residents in the survey sample, Resident #247.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to report a potential crime in a timely manner to the state agency.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide evidence that required clinical information was provided to the receiving facility at the time of discharge for two of 41 residents in the survey sample, Residents #73 and #24.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for three of 41 residents in the survey sample, Residents #72, #78 and #80.

Inspectors wroteBased on observation, facility document review, clinical record review, and facility document review, the facility staff failed to develop a complete baseline care plan for one of 41 residents in the survey sample, Resident # 246.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the care plan for one of 41 residents in the survey sample, Resident #45.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications and treatments for two of 41 residents in the survey sample, Residents #147 and #63.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of providing ADLs (activities of daily living) for two of 41 residents, Resident #42 and Resident #8.

Inspectors wrote2. For Resident #246 (R246), the facility staff failed to provide evidence of skin checks and device cleaning for the resident's use of a neck stabilizing collar. On the following dates and times, R246 was observed in his room wearing a neck stabilizing collar: 11/28/23 at 9:50 a.m. and 3:53 p.m., and 11/30/23 at 10:04 a.m. A review of R246's clinical record revealed the following order dated 11/8/23: Aspen (neck stabilizing) collar at all times every shift for support. Further review of R246's orders failed to reveal evidence of orders to check R246's skin or to clean the collar. A review of R246's baseline care plan dated 11/8/23 revealed no information at all related to R246's neck stabilizing collar. On 11/30/23 at 9:53 a.m., LPN (licensed practical nurse) #4 was interviewed. [...]

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement a complete pain management program for one of 41 residents in the survey sample, Resident #197.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the staff failed to provide trauma informed care for one of 41 resident in the survey sample, Resident #5.

Inspectors wroteBased on, staff interview and facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 41 residents in the survey sample, Resident #5.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for one of seven residents in the medication administration observation, Resident #198.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to administer medications at an error rate of less than five percent for one of seven residents in the medication administration observation, Resident #198.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to offer a influenza vaccination and/or pneumococcal vaccination for two of five residents in the infection control task/review, Residents #48 and #72.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to serve meals in a manner to promote resident dignity for two of 50 residents in the survey sample, Residents #32 and #95; and during the evening meal on 4/24/22 in two of two dining rooms.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide a resident's comprehensive care plan goals to the receiving facility at the time of discharge for one of 50 residents in the survey sample, Resident #32. The facility failed to evidence that Resident #32's (R32's) care plan goals were sent to the hospital when the resident was discharged on 2/6/22.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility failed to complete an accurate MDS (minimum data set) for four of 50 residents in the survey sample, Residents #108, #105, #23, and #83.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 1 of 50 residents in the survey sample, Resident #55. The facility staff failed to review and revise Resident #55's (R55) comprehensive care plan for the use of side rails.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 2 of 50 residents in the survey sample; Residents #317 and #98.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure respiratory care and services were provided in a sanitary manner for 2 of 50 residents in the survey sample, Residents #209 and #59.

Inspectors wroteBased on staff interview, facility document review and clinical record review it was determined that the facility staff failed to act in a timely manner on the pharmacy medication regimen review for one of 50 residents in the survey sample, Resident #47 (R47). R47's medication regimen review was completed on 1/13/2022 with recommendations for a gradual dose reduction of the antipsychotic medication which were not addressed by the facility physician until after 3/9/2022.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide services to prevent a resident from receiving unnecessary psychoactive medications for two of 50 residents in the survey sample, Residents #91 and #23.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for 1 of 50 residents in the survey sample; Resident #317.

Inspectors wroteBased on staff interview and employee record review, it was determined that the facility staff failed to ensure that one of five CNA (certified nursing assistant) records reviewed received the required dementia training.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to transmit MDS (minimum data set) OBRA (Omnibus Budget Reconciliation Act) tracking records and assessments to CMS (the Centers for Medicare and Medicaid Services) for 6 of 50 residents in the survey sample, Residents #6, #8, #9, #10, #11 and #12.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure all required information was provided to the receiving health care institution for eight of 42 residents in the survey sample, Residents #63, #18, #43, #81, #79, #28, #48 and #23. 1. The facility staff failed to provide Resident #63's comprehensive care plan goals to hospital staff when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to ensure Resident #18's comprehensive care plan goals were sent with the resident to the hospital at the time of transfer on 3/4/19. 3. The facility staff failed to evidence that Resident # 43's comprehensive care plan goals were sent with the resident to the hospital for the transfer dated 3/5/19. 4. [...]

Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility staff failed to serve food in a sanitary manner and failed to maintain infection control practices during the lunch meal in two of five dining areas, second floor multi-purpose room and the Dining Hall on the first floor. 1. OSM (other staff member) #1 (the dietary catering associate) touched her face with gloved hands multiple times while serving food to residents in the second floor multi-purpose room. OSM #1 failed to change gloves or wash her hands after touching her face, and continued to serve food. 2. [...]

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to serve food in a dignified manner for one of 42 residents in the survey sample; Resident #88. The facility staff failed to ensure Resident #88 was served the lunch meal in a home like manner on 3/20/19. LPN (Licensed Practical Nurse) #4 placed Resident #88's tray on the table without removing the plate, cups, and utensils from the tray. Resident #88 was observed eating his food from the tray, cafeteria style and not in a homelike manner.

Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that the facility staff failed to maintain confidentiality for one of 5 residents in the medication administration observation, Resident #83. The facility staff failed to ensure Resident #83's confidentiality by leaving medication packages that contained the resident's name, drug name and strength on top of the medication cart.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 42 residents in the survey sample, Resident #48 and #17. 1. The facility staff failed to review and revise Resident #48's comprehensive care plan when the bed alarm was discontinued. 2.a. The facility staff failed to review and revise Resident #17's care plan when the medication Ativan was discontinued. 2.b. The facility staff failed to review and revise the comprehensive care plan to include the physician ordered feeding instructions for Resident #17.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of five residents in the medication administration observation, Resident #407. LPN (Licensed practical nurse) #2 failed to administer medication labeled with Resident #407's name to the resident. Instead, LPN #2 borrowed medication labeled with Resident #408's name and administered the medication to Resident #407.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure one of 42 residents in the survey sample, received the care and services in accordance with professional standards and the comprehensive care plan for Resident #17. The facility staff failed to follow the physician ordered feeding instructions for Resident #17. During separate observations the facility staff were observed feeding Resident #17 without the resident being positioned at 90 degrees as ordered by the physician.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for two of 42 residents in the survey sample, Residents #21 and #28. 1.a. The facility staff failed to obtain a physician's order for an incentive spirometer that was observed in Resident #21's room and available for the resident's use. 1.b. The facility staff failed to store Resident #21's incentive spirometer mouthpiece in a clean and sanitary manner. 2. The facility staff failed to store oxygen tubing in a sanitary manner for Resident #28.