Below 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 Leewood during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident with altered mental status developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped both wrists against a wheelchair during transfer. An RN completed an incident report and nursing note documenting the injury, assessment, and physician notification with an order for x-ray. Facility leadership later acknowledged that this event, which met their policy criteria for an allegation requiring reporting within two hours if involving abuse or serious bodily injury, was not reported to the state survey agency, contrary to the facility’s written abuse, neglect, and exploitation policy.
A resident with moderately impaired cognition and a preferred language other than English developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped her wrists on a wheelchair. Documentation noted the injury, assessment, and treatment, but the care plan was not updated. A family member reported that the resident said staff grabbed her hand and tried to force care, and this was reported to nursing and administration. Despite this allegation, the facility did not conduct a full abuse investigation per its policy: the Social Service Director did not interview the resident or other cognitively intact residents or complete a trauma assessment, and the Administrator/DON confirmed that only the involved CNA and RN were interviewed before concluding no abuse occurred.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Failure to Timely Report Allegation of Potential Abuse-Related Injury
Penalty
Summary
The facility failed to timely report an allegation of potential abuse related to an injury sustained by Resident 94 during ADL care. Resident 94, who had a diagnosis including altered mental status, was admitted on an unspecified date and later developed discoloration and swelling of both wrists during clothing changes and transfer by a CNA. An incident report dated 03/20/25 at 9:45 PM, written by an RN, documented that the CNA reported the resident developed bilateral wrist discoloration during ADL care while the resident was resisting, and that the resident bumped both wrists against the wheelchair during transfer. The RN’s documentation noted assessment of the resident’s wrists, presence of discoloration and swelling, and that the physician was notified and ordered an x-ray to rule out fracture, with ice applied to the affected areas. Interviews with facility leadership confirmed that this incident was not reported to the state survey agency (SSA). The CEO stated that the incident from 03/20/25 was not reported to the SSA. The Administrator, who was the DON at the time of the incident, stated that the facility’s practice was to report all allegations of abuse or injury of unknown origin within two hours, but acknowledged that this allegation was not reported because they determined it was not an injury of unknown origin or abuse. Review of the facility’s Abuse, Neglect and Exploitation policy, revised 11/2021, showed a requirement to report all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury.
Failure to Investigate Allegation of Abuse After Resident Wrist Injury
Penalty
Summary
The facility failed to investigate an allegation of potential abuse after a resident sustained bilateral wrist injuries during ADL care by a CNA. The resident, who had moderately impaired cognition with a BIMS score of 11 and whose preferred language was Korean, was admitted with altered mental status. On the date of the incident, an incident report documented that the CNA informed an RN that the resident developed discoloration and swelling of both wrists during clothing changes when the resident was resisting care and bumped her wrists against the wheelchair during transfer. A nurse’s note recorded similar information, stating that the resident developed bilateral wrist discoloration and swelling after an accident during clothing changes while the resident was resisting, and that ice was applied and an x-ray was ordered to rule out fracture. The resident’s care plan, which addressed discoloration, was not updated after the wrist injuries occurred. The facility did not conduct a comprehensive abuse investigation as required by its policy. The CEO acknowledged there was no investigation for the incident and only produced a grievance document. A family member reported that the resident told her staff grabbed her hand and tried to force her when she refused to be changed, and that this allegation was reported to a nurse and the prior Administrator. The Social Service Director stated that, in abuse investigations, she typically interviews the resident and five other cognitively intact residents and completes a trauma assessment, but she did not interview this resident, did not interview other residents, and did not complete a trauma assessment related to this incident. She reported that the facility held a meeting and determined abuse did not occur but was unsure how that conclusion was reached. The Administrator, who was the DON at the time, stated that after allegations of abuse they immediately start an investigation, but in this case they only interviewed the involved CNA and RN and relied on the CNA’s denial of abuse and explanation that the injury occurred during ADL care, without interviewing the resident, witnesses, or others as required by the facility’s abuse, neglect, and exploitation policy.
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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 Annandale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Annandale Healthcare Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Greenspring Village | 3.1 mi | ★★★★★ | 0 | 0 |
| Goodwin House Alexandria | 4.5 mi | ★★★★★ | 0 | 0 |
| Goodwin House Bailey's Crossroads | 4.7 mi | ★★★★★ | 0 | 0 |
| Carlin Springs Health & Rehabilitation | 4.7 mi | ★★★★★ | 0 | 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.