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 August Healthcare At Iliff during CMS and state inspections, most recent first.
Staff failed to develop a baseline care plan within 48 hours of admission for a resident who was completely dependent for ADLs, incontinent, vegetative, ventilator-dependent, and admitted with an existing sacral/coccyx pressure area documented as skin maceration. Multiple admitting skin assessments recorded the sacral impairment, and a later weekly skin review described an unstageable sacral pressure ulcer with necrosis and slough, yet no physician treatment orders or comprehensive care plan addressing the wound were in place until several days after admission. In interviews, the RN and DON acknowledged that the wound was believed to be a hospital-acquired deep tissue injury present on admission, and the DON could not explain why treatment orders or a care plan were not initiated upon admission.
Staff failed to obtain and initiate timely treatment orders and a baseline care plan for a dependent, vegetative resident admitted with a known sacral/coccyx pressure area. Admission and subsequent skin assessments documented a sacral maceration and later an unstageable pressure ulcer with necrosis and slough, yet no wound treatment orders were in place for the first five days after admission, despite facility policies requiring skin assessments and treatments as needed. Wound care orders, including a wound-healing supplement, weekly skin checks, and sacral cleansing and dressings, were only started later, after the ulcer was already documented as unstageable.
Staff failed to follow professional standards for medication administration and documentation for a resident receiving a Rivastigmine transdermal patch for dementia. Review of MARs showed unclear and conflicting removal times for the 24‑hour patch and inconsistent adherence to the physician’s bedtime order, with two different removal times documented on both the March and April records. In addition, staff did not document the anatomical sites where patches were applied, despite the DON stating that documenting patch sites was important. During a med pass observation, interviewed LPNs affirmed the importance of following physician orders, yet the MAR entries did not clearly demonstrate compliance with those orders or with accepted standards for transdermal patch use.
A resident with Parkinson’s disease, atrial fibrillation/flutter, chronic heart failure, type 2 diabetes, and hypertension did not receive multiple ordered medications over several days because they were repeatedly documented by nursing staff as not available or awaiting pharmacy delivery. The missing drugs included rivastigmine patch, amantadine ER, DDAVP nasal solution, clobetasol foam, amiodarone, ergocalciferol, and Rytary, all with valid physician orders. An LPN stated medications should be available by the day after admission, and the DON reported that pharmacy delivered twice daily and that new admission medications should be available by the next day, yet documentation continued to show unavailability. A pharmacy manifest showed one medication had been delivered despite being charted as unavailable, and a Pixus review confirmed the cited medications were not stocked there, demonstrating a failure to ensure timely availability of ordered medications.
Failure to Develop Timely Baseline Care Plan for Existing Sacral Wound
Penalty
Summary
Facility staff failed to develop a baseline care plan within 48 hours of admission to address an existing skin impairment for one resident. The resident was admitted with multiple serious diagnoses, including post-infectious viral encephalitis and encephalomyelitis, acute cerebral edema, intracranial space-occupying lesion, persistent vegetative state, ventilator dependence, and an unstageable coccyx/sacral pressure sore. The admission MDS documented the resident as completely dependent on 1–2 staff for all ADLs, incontinent of bowel and bladder, and vegetative with no response to verbal or physical stimuli. On the first admitting daily skin assessment, staff documented an existing sacral pressure ulcer and noted that what had been referred to as a healed stage 2 on the sacrum was actually mild skin maceration, measuring 5 cm by 6 cm with no depth. Subsequent admitting daily skin assessments on the following days continued to document skin maceration in the coccyx/sacrum area. Despite these documented findings, there were no physician treatment orders for the pressure area from admission until several days later, and the comprehensive care plan addressing the wound was not initiated until after treatment orders were obtained. A weekly skin review documented an open area on the sacrum, an unstageable pressure ulcer with moderate necrosis and slough tissue, measuring 5 cm by 8 cm, with low air loss mattress in use and no change in treatment. During interviews, the Pediatric Director RN stated that the physician believed the pressure sore was hospital-acquired and just beginning to break down on admission, and the DON stated that everyone knew the wound was a deep tissue injury that occurred in the hospital. When asked why treatment orders or a care plan were not obtained or instituted upon admission if this was known, the DON responded, "I don't know." The facility acknowledged the findings and had no further information to present at the time of exit.
Failure to Initiate Timely Treatment for Admitted Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to provide timely treatment and baseline care planning for a known pressure area on the sacrum of one resident during the admission period. The resident was admitted with multiple serious diagnoses, including post-infectious acute viral encephalitis and encephalomyelitis, acute cerebral edema, intracranial space-occupying lesion, persistent vegetative state, ventilator dependence, and an unstageable coccyx/sacral pressure sore. The admission MDS documented the resident as completely dependent on 1–2 staff for all ADLs, incontinent of bowel and bladder, and vegetative with no response to stimuli. Daily admitting skin assessments beginning on 12-30-24 documented an existing sacral/coccyx pressure area described as skin maceration measuring 5 cm by 6 cm with no depth, and later as skin maceration of the sacrum, but no physician treatment orders were obtained from admission through 1-3-25. Despite the presence of wound evaluation documents and recognition by staff and physician that there was a pressure area present on admission, no wound treatment orders were in place or implemented for the first five days. On 1-4-25, staff obtained and initiated new physician orders for wound care and related interventions, including a dietary supplement for wound healing twice daily, weekly skin checks, and cleansing and dressing of the sacral wound with hydrofera and a dry dressing. A weekly skin review on 1-9-25 documented an open area on the sacrum with hydrofera in progress, describing the pressure ulcer as unstageable with moderate necrosis and slough tissue, measuring 5 cm by 8 cm, with no tunneling or signs of infection and no change in treatment. Interviews with the Pediatric Director RN and the DON confirmed that staff believed the wound to be a deep tissue injury acquired in the hospital and present on admission, yet the DON could not explain why treatment orders and a care plan were not obtained and initiated upon admission. Facility policies required weekly skin assessments and obtaining treatments as needed, but the record showed that no treatment orders for the pressure ulcer were obtained or started during the initial five-day period after admission.
Failure to Follow Professional Standards for Transdermal Patch Administration and Documentation
Penalty
Summary
Facility staff failed to ensure professional standards of quality in medication administration for one cognitively intact resident with multiple chronic conditions, including Parkinson's disease, atrial fibrillation/flutter, chronic heart failure, type 2 diabetes, and hypertension. Review of the closed electronic clinical record and the March and April 2025 Medication Administration Records (MARs) showed that medications were not administered as ordered by the physician. Specifically, the Rivastigmine 9.5 mg/24 hr transdermal patch, ordered to be applied at bedtime for dementia and removed per schedule, had unclear and inconsistent removal times documented. The March MAR showed an order start date of 3/15/2025 and discontinue date of 3/27/2025, with entries to remove the patch at both 1:18 p.m. and 7:59 p.m., and to apply the patch at 8:00 p.m. The April MAR similarly listed two removal times, 2:33 p.m. and 7:59 p.m., with application at 8:00 p.m. The MARs also lacked documentation of the anatomical sites where the Rivastigmine patches were applied, despite the DON acknowledging that documenting patch sites was important so staff would know where patches had been placed. During medication pass observations, interviewed LPNs stated it was important for nurses to administer medications and follow physician orders, yet the MAR documentation did not clearly reflect adherence to those orders or to professional standards for transdermal patch use. Reference materials cited in the report, including Lippincott Nursing Procedures and external guidance on transdermal patches, emphasized the need to follow physician orders, facility policies, and proper documentation, as well as the importance of rotating patch sites, underscoring the deficiencies identified in the resident’s medication administration records.
Failure to Ensure Availability of Ordered Medications for a New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available for administration to a resident, as required under pharmaceutical services. The affected resident was an older adult admitted with multiple diagnoses including Parkinson’s disease, atrial fibrillation/flutter, chronic heart failure, type 2 diabetes, and hypertension, and had no cognitive impairment per a recent MDS, requiring assistance with ADLs. Review of the closed electronic clinical record and nurses’ notes showed repeated documentation that several ordered medications were not available for administration on multiple consecutive days (3/15/2025, 3/16/2025, and 3/17/2025). These medications included, but were not limited to, rivastigmine patch, amantadine ER, DDAVP nasal solution, clobetasol foam, amiodarone, ergocalciferol, and Rytary, all of which had valid physician orders. Nursing documentation repeatedly indicated that medications were “not available” or “awaiting pharmacy delivery” over several medication administration times, including bedtime and scheduled daily doses. Some medications listed as unavailable on 3/15/2025 and 3/16/2025 continued to be documented as unavailable on 3/17/2025. Interview with an LPN confirmed that medications should be available for administration and that nurses should try to obtain medications by the day after admission. The DON stated that medications were expected to be available as ordered, that the pharmacy had two scheduled daily deliveries, and that new admission medications should be available by the next day, but acknowledged that a rivastigmine patch documented as unavailable had in fact been delivered earlier that day per the pharmacy manifest. Review of the Pixus inventory showed none of the cited medications were available there. During the end-of-day debriefing, facility leadership acknowledged that medications should be available for administration as ordered.
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Nursing homes near Dunn Loring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Boulevard Post Acute | 2.9 mi | ★★★★★ | 1 | 0 |
| Vierra Falls Church | 3.3 mi | — | 3 | 0 |
| Arleigh Burke Pavilion | 4.2 mi | ★★★★★ | 0 | 0 |
| Annandale Healthcare Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Carlin Springs Health & Rehabilitation | 5.4 mi | ★★★★★ | 0 | 0 |
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