Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Dulles Health & Rehab Center during CMS and state inspections, most recent first.
Multiple residents had care plan failures involving incontinence care, bathing, oxygen therapy, contact precautions, anticoagulation monitoring, and TED hose use. Surveyors observed missing ADL documentation, inconsistent showers, oxygen delivered at the wrong flow rate, an uncovered nebulizer mask, a CNA entering a contact isolation room without PPE, and no evidence of anticoagulation monitoring or a care plan for TED hose use.
Failure to Monitor Anticoagulant Therapy: The facility failed to document monitoring for residents receiving anticoagulants. A resident receiving Enoxaparin and three residents receiving Apixaban/Eliquis had MAR-TARs showing the medications were given as ordered, but the records did not show evidence of routine monitoring for bleeding or bruising. An LPN stated anticoagulant monitoring should include observing for these side effects because it is a patient safety issue.
Unsafe Food Storage and Utensil Handling in Kitchen: The kitchen had a carton of thickened apple juice with a use-by date in dry storage, stacked meatloaf pans with visible debris, steam tray pans with visible moisture on the outside, and a thickener bin with a scoop resting inside the product. The FSD stated the vendor-sent juice should have been rejected and that the scoop should be stored on top of the bin rather than inside the thickener.
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Call Light Not Kept Within Reach: A resident with severe cognitive impairment and right-sided non-functioning was observed in a wheelchair with the touch pad call bell clipped to the bed on the resident’s right side, out of reach of the left hand. The resident indicated the call bell could not be reached until an LPN moved it to the wheelchair tray, where it became accessible. The resident’s care plan included keeping personal items within reach, and the facility policy stated call lights should be available to allow residents to call for assistance.
A resident admitted with cellulitis and chronic lower extremity ulcers was ordered IV Daptomycin for 28 days, but one scheduled dose was not administered because the medication had not arrived from the pharmacy. The record documented that the dose was waiting for pharmacy arrival, but there was no evidence that the physician was notified or that the missed dose was documented as required.
Failure to Provide Written Transfer Notice: A resident was transferred to the hospital for fever, low O2, and a slow response, but the facility did not provide a written transfer notice to the resident, the resident representative, or the ombudsman. The DON/Social Services process described mailing notice to family, documenting it on a form, and sending weekly encrypted emails to the ombudsman, but no notice was found in the record or ombudsman binder.
Failure to implement baseline wound care on admission. A resident admitted with cellulitis and multiple wounds had a baseline care plan identifying pressure injuries to both buttocks and cellulitis wounds to both calves, but the clinical record did not show wound treatment being started right away. The eTAR showed treatment for the buttock wounds began later, followed by treatment for the calf wounds, after the wounds had already been documented on admission and during body audits.
Failure to provide ordered wound care and TED stockings. One resident admitted with cellulitis, chronic venous insufficiency, and bilateral lower-extremity wounds had wounds identified on admission, but the record did not show treatment before the wound orders began, despite staff stating wound treatment should be entered and documented when wounds are found. Another resident with edema and a history of venous thrombosis had physician-ordered TED stockings, but observations showed the stockings were not being worn and the care plan did not document their use.
A resident admitted with cellulitis and chronic leg ulcers had pressure injuries to both buttocks identified on admission and confirmed on body audit as DTIs with maroon/purple tissue. The record did not show wound treatment before the orders and eTAR entries began, despite staff stating that admission nurses should review discharge instructions, obtain orders if needed, and document treatment in the eTAR and care plan.
Failure to provide ordered GJ stoma site care for a resident with a feeding tube. The resident’s record showed tube feeding and a care plan for the insertion site, but the MD orders did not include stoma care orders. An LPN described changing the dressing and dating it, while an RN said stoma care was done daily and as needed and would follow MD orders; facility policy called for cleansing the peristomal area and applying a dressing per provider order.
Improper IV Antibiotic Administration: An RN administered oral meds, eye drops, and an injection to a resident while wearing the same gloves, then accessed the resident’s central venous access and connected IV Daptomycin without changing gloves or re-sanitizing hands. The resident had an order for daily IV Daptomycin for a wound infection, and an LPN stated gloves should be changed and hands sanitized before accessing a central venous access; the facility’s hand hygiene policy also stated gloves do not replace hand hygiene.
A resident with respiratory failure and COPD did not receive oxygen at the ordered 3 L/min via NC; the O2 concentrator was observed set between 2.5 and 3 L/min on multiple occasions. Staff also left the resident’s nebulizer mask uncovered on the bedside table when not in use, rather than storing it in a sanitary manner. An LPN acknowledged the oxygen setting should match the order and that the nebulizer mask should be protected from contamination.
A resident with ESRD, CVA, hemiplegia/hemiparesis, and DM had an order for dialysis transport on M/W/F and a care plan calling for coordination and regular communication with the dialysis center. The dialysis communication book was missing multiple pre/post weight entries, and an LPN confirmed the documentation was incomplete and that weights are to be documented; the facility policy also identified pre- and post-weights as part of dialysis communication.
Expired liquid cimetidine for a resident was found in the medication refrigerator, and an LPN left two residents’ medication cups unattended on top of a med cart during med pass. The LPN stated the meds should have been placed inside the cart and not left where someone could take them.
Dietary preferences were not honored when a resident’s meal tray included fish even though fish was listed on the dislike list. The resident was cognitively intact with DM, CHF, and MI, and the care plan and dietary note indicated that food preferences were discussed and relayed to the kitchen. Staff described a process for matching meal tickets to trays before delivery, but the tray still contained the disliked item.
Inaccurate Skilled Nursing Documentation: A resident with cellulitis wounds, pressure injuries, and anticoagulant therapy had skilled notes that incorrectly stated the resident was not on anticoagulants, not receiving infection-related care, and had no wounds being monitored or treated. The resident’s record also showed IV antibiotics, apixaban for DVT, and documented wounds to both lower extremities and buttocks, while an RN later stated the notes could not be considered accurate.
Infection control practices were not followed for two residents on contact precautions and during medication administration for another resident. A CNA entered a room under contact precautions without gown or gloves, and a staff member entered another contact precautions room without hand hygiene or PPE before handling meal trays. In addition, an RN administered oral meds, eye drops, and an injection without changing gloves or sanitizing hands between tasks, despite facility policy requiring hand hygiene and glove changes.
Multiple Care Plan Implementation Failures
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for multiple residents, including care related to incontinence, bathing, oxygen therapy, contact precautions, anticoagulation monitoring, and TED hose use. Surveyors identified missing documentation and observed care not being carried out as planned for residents with significant medical needs, including residents with bowel and bladder incontinence, severe cognitive impairment, quadriplegia, anoxic brain injury, dementia, COPD, respiratory failure, CVA, ESRD, and other diagnoses. In several cases, the care plans contained interventions such as toileting assistance, showering, oxygen administration, or monitoring for bleeding, but the record and observations did not show those interventions were consistently implemented. For one resident who was frequently incontinent of bowel and bladder and dependent on staff for toileting, the ADL record did not show toileting hygiene on two night shifts. Another resident with quadriplegia and anoxic brain damage was assessed as always incontinent and dependent for toileting hygiene, and the resident’s agent reported concern that the resident appeared to have a wet brief for hours. A resident with dementia and dependence for bathing received only two showers in a two-week period despite a care plan calling for bathing and hygiene assistance as required. For two residents with severe cognitive impairment and dependence for ADLs, the ADL records showed multiple missing entries for incontinence care, turning, and positioning on numerous dates and shifts. Surveyors also observed failures in treatment-related care. A resident ordered to receive oxygen at 3 L/min continuously was observed on multiple occasions receiving oxygen at a lower flow rate of between 2.5 and 3 L/min, and the resident’s nebulizer mask was repeatedly observed uncovered on the bedside table rather than stored in a sanitary manner. Another resident on contact precautions for CRE was observed when a CNA entered the room and turned off the call light without donning gown or gloves. In addition, residents on anticoagulation therapy had no evidence of anticoagulation monitoring documented in the MAR-TAR, and one resident ordered to wear TED hose had no care plan developed to address that intervention.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to monitor residents receiving anticoagulant medications for side effects and signs of bleeding or bruising, resulting in a deficiency for unnecessary drugs. For Resident #2, the clinical record showed an order for Enoxaparin sodium injection every 12 hours, and the MARs showed the medication was administered as ordered each day, but the record did not show evidence of monitoring for side effects. An LPN stated that residents receiving anticoagulants have a higher risk of bleeding or bruising and that nursing staff should monitor for these side effects each shift and document the monitoring on the MAR. For Resident #8, the record showed a diagnosis history including CVA, hemiplegia/hemiparesis, DM, and ESRD, with a quarterly MDS indicating no cognitive impairment and extensive assistance needs for mobility and self-care. The care plan identified anticoagulant therapy as a focus and directed staff to report signs or symptoms of new or unusual bleeding or bruising, and the physician ordered Apixaban for atrial fibrillation. The MAR-TAR showed Apixaban was administered as ordered, but there was no evidence of anticoagulation monitoring documented during the reviewed period. For Resident #10, the record showed diagnoses including osteoarthritis, dementia, atrial fibrillation, and COPD, with severe cognitive impairment and dependence for multiple activities of daily living. The physician ordered Apixaban for unspecified atrial fibrillation, and the MAR-TAR showed the medication was administered as ordered, but there was no evidence of anticoagulation monitoring. For Resident #1, the record showed diagnoses including DM, CHF, and MI, with no anticoagulant care plan until later in the review period; the physician ordered Eliquis for atrial fibrillation, the MAR-TAR showed administration as ordered, and there was no evidence of anticoagulation monitoring documented.
Unsafe Food Storage and Utensil Handling in Kitchen
Penalty
Summary
Food was not served in a safe and sanitary manner in the kitchen. During observation with the food service director, a 46 fluid ounce carton of thickened apple juice was found in dry storage with a documented use-by date. In the kitchen, a wire shelving rack held six stacked meatloaf pans that the director said were clean and available for use, but two of the pans had visible debris adhering to the inside. Another wire shelving rack in the cooking area held two stacks of steam tray pans, one stack of four and one stack of three, and the director stated they were clean and available for use; however, one pan in each stack had visible water droplets on the outside. A 22-quart bin labeled thickener was observed on the countertop containing approximately 14 quarts of product, with a plastic scoop resting inside the thickener. During interview, the food service director stated she had pulled the thickened apple juice off the shelf because it should have been rejected by the vendor, that the meatloaf pans had been re-washed to remove debris, that staff had been educated on air drying pans before stacking them, and that the thickener scoop should be kept on top of the bin rather than inside the product for infection control purposes. The administrator, DON, and ADON were informed of the findings.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to accommodate the needs and preferences of one resident by not keeping the call light within reach. During an observation, the resident was seated in a wheelchair beside the bed, and the touch pad call bell cord was clipped to the edge of the bed with the TV remote control on the resident’s right side. The resident was unable to reach the call bell across the body with the left hand and indicated that the call bell was not reachable. The resident was admitted with diagnoses including epilepsy, traumatic brain injury, schizophrenia, and psychotic delusions, and the most recent MDS coded the resident as severely cognitively impaired with dependence for locomotion, transfer, dressing, toileting, and hygiene. The resident was documented as non-functioning on the right side. The care plan included an intervention to place personal items and water within reach, and the facility’s policy stated that call lights should be available at the bedside, toilet, and bathing area to allow residents to call for assistance. When an LPN observed the situation, he confirmed the resident could not reach the call bell in its original location and moved it to the wheelchair tray, where the resident could then reach it. The LPN stated it was a safety issue if the resident could not call for assistance.
Failure to Notify Physician When Ordered IV Antibiotic Was Not Given
Penalty
Summary
The facility failed to notify the physician that Resident #182 did not receive the ordered Daptomycin intravenous dose on 3/21/2026 at 5:00 PM. Resident #182 was admitted with diagnoses including cellulitis and chronic lower extremity ulcers, and the physician order documented Daptomycin 600 mg intravenously in the evening for cellulitis for 28 days, with a start date of 3/21/2026. The eMAR showed the 5:00 PM dose was coded as 9, with chart code .9 indicating other/see nurses notes. The progress notes documented that the resident arrived to the facility on 3/20/2026 with a central line in the right upper chest and was receiving IV Daptomycin for cellulitis. On 3/21/2026, a note stated that the Daptomycin was waiting for pharmacy arrival. The clinical record did not show that the physician was notified that the dose was not administered. During interviews, an LPN stated that if a medication had not arrived from the pharmacy, the nurse should call the physician and document that the physician and resident were notified. An RN stated that if a medication had not arrived, the physician should be notified to determine whether treatment should be extended, and that this would be documented in the medical record.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for Resident #6 when the resident was transferred to the hospital on 2/28/26 for fever, low oxygen, and a slow response. Review of the clinical record and a facility binder containing ombudsman notices did not show that a written transfer notice was provided to the resident, the resident's representative, or the ombudsman. During an interview on 3/24/26, the Director of Social Services stated that when a resident is transferred to the hospital, she sends written notification to the resident's family by mail, documents the date on a written notification form, and sends a weekly encrypted email of all transfers to the ombudsman. She also stated that she provides the written notification form to the resident if and when the resident returns to the facility. She stated she was on leave when Resident #6 was transferred and her social services team was new. The Administrator and Director of Nursing were informed of the concern on 3/24/26. The facility policy titled Notification of Discharge stated that discharge notices for emergent discharges will be provided to the patient/representative as soon as practicable and that copies of notices for emergency transfers must also be sent to the ombudsman.
Failure to Implement Baseline Wound Care on Admission
Penalty
Summary
The facility failed to implement the baseline care plan for a resident admitted with cellulitis and chronic lower extremity ulcers. The baseline care plan, initiated on 3/20/2026 and revised on 3/23/2026, documented that the resident was at risk for or had actual skin breakdown, including pressure injuries to both buttocks, cellulitis wounds to both calves, and redness under both breasts. The care plan also directed staff to assess the skin thoroughly and implement precautions and/or treatment as indicated. On admission, the nursing assessment documented cellulitis on both lower extremities, wounds to both lower extremities, excoriation to the sacrum, and open areas on both buttocks. A body audit on 3/20/2026 documented the same findings. A subsequent body audit on 3/21/2026 described a deep tissue injury to the right buttock and left buttock, necrotic tissue with purulent drainage in the left posterior calf wound, and granulation tissue with moderate serous drainage in the right posterior calf wound. The physician orders for wound care were not entered until 3/23/2026, with start dates of 3/23/2026 for the left buttock pressure injury and 3/24/2026 for the calf wounds. Review of the eTAR showed treatment to the buttock pressure injuries beginning on night shift 3/23/2026 and treatment to the calf wounds beginning on evening shift 3/24/2026. The clinical record did not evidence treatment to the wounds prior to those dates.
Failure to Provide Ordered Wound Care and TED Stockings
Penalty
Summary
The facility failed to provide ordered treatment for a resident with bilateral venous wounds identified on admission. The resident was admitted with diagnoses including cellulitis, chronic venous insufficiency, and chronic lower extremity ulcers. Admission documentation and body audits identified cellulitis wounds on both posterior calves, including necrotic tissue and purulent drainage on the left calf wound and granulation tissue with moderate serous drainage on the right calf wound. The physician later entered wound care orders for cleansing and dressing changes, but the clinical record did not evidence treatment to the wounds before the orders began on the evening shift of 3/24/2026. The resident stated that compression wraps had slipped down at home and that the resident had developed cellulitis in the lower legs and was at the facility for a 28-day course of antibiotics. Facility staff interviews indicated that when a wound was identified on admission, the nurse should review hospital discharge instructions for wound treatment orders and, if none were present, contact the physician for orders. Staff also stated that the admission nurse normally entered initial treatment and that wound treatment should be documented in the eTAR. However, the record failed to show treatment for the bilateral calf wounds prior to 3/24/2026 despite the wounds being identified on admission and included on the baseline care plan. The facility also failed to apply TED stockings according to physician orders for another resident. The resident had diagnoses including embolism and thrombosis of superficial veins of the left lower extremity and was cognitively intact. The physician ordered TED stockings to be worn during the day and removed in the evening for edema, but observations on two separate occasions showed the resident’s lower legs without TED stockings. During an observation with an LPN, the resident was not wearing TED stockings on either leg, and the LPN stated they were used to prevent swelling. The care plan did not include documentation for the use of TED stockings, and the facility policy stated stockings are to be applied in accordance with physician orders and checked daily.
Failure to Initiate Pressure Injury Treatment
Penalty
Summary
The facility failed to implement treatment for pressure injuries identified on admission for one resident who was admitted with diagnoses including cellulitis and chronic lower extremity ulcers. The admission/readmission skin assessment documented excoriation to the sacrum and open areas on both buttocks, and a body audit the next day documented a deep tissue injury to the right buttock and a deep tissue injury to the left buttock with dark maroon/purple tissue, no drainage, and surrounding skin redness. The clinical record showed physician orders for zinc oxide paste and cleansing of the left and right buttock pressure injuries beginning on 3/23/2026, and the eTAR documented treatment to the left and right buttock pressure injuries beginning on night shift 3/23/2026. Review of the record did not show treatment to the wounds before 3/23/2026, despite the wounds being identified on admission and during the subsequent body audit. Staff interviews indicated that when a wound was identified on admission, the nurse was expected to review hospital discharge instructions for wound treatment orders and contact the physician if no orders were present. Staff also stated that the admission nurse typically entered initial treatment, the wound nurse assessed the resident the next day, and wound treatment would be documented in the eTAR. The facility policy stated that interventions for a pressure injury would be documented in the care plan and that compliance with interventions would be documented in the medical record.
Failure to Provide Ordered GJ Stoma Site Care
Penalty
Summary
The facility failed to provide care for Resident #17’s gastrojejunostomy (GJ) stoma site consistent with professional standards of practice. The resident’s most recent MDS annual assessment, with a reference date of 2/5/2026, documented that the resident had a feeding tube and received 51% or more of calories from enteral feeding. The physician’s orders documented tube feeding and water flushes, but did not include orders for GJ stoma site care. The resident’s discharge instructions from 12/12/2025 stated that the skin around the tube and under the skin disk should be cleansed daily with soap and water and dried thoroughly. The comprehensive care plan stated that the insertion site would be free of signs and symptoms of infection and that stoma site care would be provided per MD order or facility policy, with reference to the TAR. During interviews on 3/25/2026, an LPN stated that she changed the dressing and wrote the date on it, and that night shift usually changed the dressing. An RN stated that stoma care was done daily at 6:00 AM and as needed and that he would follow the doctor’s orders. The facility policy for care of a patient with a feeding tube stated that the stoma area would be cleaned and a dressing applied by a licensed nurse as indicated in accordance with the medical provider’s order, and that the peristomal area may be cleansed with soap and water using a spiral pattern.
Improper IV Antibiotic Administration
Penalty
Summary
The facility failed to administer parenteral medications in a sanitary manner for a resident receiving an IV antibiotic through a central venous access. During observation, an RN prepared medications on a medication cart, sanitized her hands, donned gloves, and then touched the medication cart surfaces and lock before taking the tray to the resident. Without changing gloves, she administered oral medications, eye drops, and an injection, then removed the cap from the resident’s central venous access, cleaned the access with alcohol, and connected the tubing for Daptomycin before unclamping it to begin infusion. The resident’s record showed an order for Daptomycin Sodium Chloride Intravenous Solution 620 mg IV daily for wound infection for 6 weeks. An LPN interviewed after the observation stated that gloves should be changed and hands sanitized if gloves become contaminated, and that gloves should be removed and hands sanitized before donning new gloves and attaching an antibiotic to a central venous access. The facility policy on Hand Hygiene stated that gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them; the IV Access Device Care policy did not address the concern.
Failure to Provide Ordered Respiratory Care and Maintain Nebulizer Mask Sanitation
Penalty
Summary
Facility staff failed to provide respiratory care and services for Resident #161 by not administering oxygen according to the physician’s order. The resident was admitted with diagnoses including respiratory failure and COPD, and the most recent MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for daily decisions. The physician ordered oxygen at 3 L/min via nasal cannula continuously for respiratory failure related to COPD, and the care plan directed staff to provide oxygen as ordered. During multiple observations, the resident was seen receiving oxygen by nasal cannula, but the oxygen concentrator flow meter was set between two-and-a-half and three liters per minute rather than the ordered 3 L/min. When questioned, an LPN stated the flow meter should be read with the liter line passing through the middle of the float ball and acknowledged that the resident’s oxygen flow rate should have been 3 L/min. The manufacturer’s manual for the oxygen concentrator stated that the flow should be adjusted to the prescribed setting by centering the ball on the line marking the specific flow rate. Facility staff also failed to store the resident’s nebulizer mask in a sanitary manner when not in use. On multiple observations, the nebulizer mask was found laying uncovered on top of the bedside table. The resident had an order for formoterol fumarate inhalation nebulization solution twice daily for COPD. When the uncovered mask was observed with an LPN, she stated that the mask should be placed in a plastic bag when not in use to prevent contamination.
Missing Dialysis Communication and Weight Documentation
Penalty
Summary
The facility failed to provide evidence of communication with the dialysis facility for a resident with ESRD who was admitted with diagnoses including CVA, hemiplegia/hemiparesis, DM, and ESRD. The resident’s most recent MDS quarterly assessment coded the resident as cognitively intact with a BIMS score of 15 out of 15 and requiring maximal assistance for locomotion, transfers, dressing, toileting, and hygiene. The physician’s order directed dialysis pickup at 6:45 AM on Mondays, Wednesdays, and Fridays, and the care plan identified the resident’s renal disease requiring dialysis and a left arm shunt, with interventions to coordinate with the dialysis center and communicate regularly via pre/post treatment notes. A review of the resident’s dialysis communication book showed missing pre/post weight documentation for multiple dialysis dates, including 2/20, 2/23, 2/25, 2/27, 3/2, 3/6, 3/9, 3/13, and 3/16. During interview, an LPN described the expected dialysis care process, including checking the fistula for bruit and thrill, sending a snack or meal depending on dialysis time, and monitoring the site for bleeding, and stated the documentation was not complete and that weights are to be documented. The facility’s dialysis policy stated that communication with the dialysis center may include pre- and post-weights.
Expired Medication Stored in Refrigerator and Medications Left Unattended on Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when the facility kept a bottle of liquid cimetidine for Resident #132 in the Chesapeake unit medication refrigerator after its labeled expiration date of 3/15/26. The resident had a physician’s order dated 10/21/25 for cimetidine 300 mg/5 mL, to give 2.5 mL twice daily for gastroesophageal reflux disease. During observation on 3/24/26, the bottle was still present in the refrigerator with the expired date on the label, and an LPN later stated that expired medications should have been discarded and that nurses should check the medication refrigerator daily for expired medications. Medication storage was also not maintained securely when an LPN left two residents’ medication cups on top of medication cart #1 on the Chesapeake Unit during medication administration. The cups contained several pills and tablets and were covered only by upside-down clear plastic drinking cups while the LPN walked away from the cart and entered resident rooms, leaving the medications unattended and out of sight. During interview, the LPN stated the medications should not have been left on top of the cart and should have been placed inside the cart, and said someone could come by and take them.
Dietary Preferences Not Honored on Meal Tray
Penalty
Summary
The facility failed to honor a resident’s dietary preferences by serving fish to a resident whose meal ticket listed fish as a dislike. The resident was admitted with diagnoses including DM, CHF, and MI, and the most recent MDS coded the resident as cognitively intact with a BIMS score of 15 out of 15. The comprehensive care plan addressed altered nutritional needs related to class II obesity and DM and included an intervention to discuss food preferences with the resident/family and honor food requests as possible. A dietary progress note documented that food preferences were discussed with the resident and relayed to the kitchen. During the initial resident screening, the resident stated that everything was great except for food on meal trays that was on the dislike preference list. The lunch tray ticket for the resident listed no fish among the dislikes, yet the resident’s lunch tray included fish. Staff described the tray delivery process as checking the meal ticket against the food on the tray before giving it to the resident, and the dietary manager stated that trays are made in the kitchen based on the meal ticket and aides are to compare the tray with the ticket before delivery.
Inaccurate Skilled Nursing Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident by documenting incorrect information in the daily skilled observation and assessment notes on 3/22/2026, 3/23/2026, and 3/24/2026. The resident was admitted with diagnoses including cellulitis of both lower limbs, chronic lower extremity ulcers, and long-term anticoagulant use. The nursing admission/readmission assessment documented cellulitis with wounds on both lower extremities, open areas on both buttocks, and anticoagulant therapy, and the body audit documented wounds to both posterior calves with necrotic tissue, purulent drainage, granulation tissue, and measurable wound dimensions. Physician orders showed the resident was receiving apixaban every 12 hours for DVT, daptomycin IV in the evening for cellulitis, and piperacillin-tazobactam IV every 8 hours for cellulitis. The baseline care plan also documented the resident as at risk for or having actual skin breakdown, with pressure injuries to both buttocks, cellulitis wounds to both calves, redness under both breasts, and anticoagulant therapy placing the resident at risk for bleeding/bruising. Despite this documented condition and treatment, the daily skilled notes for the three dates recorded that the resident was not on anticoagulants, was not receiving care related to recent or ongoing infection, and did not have impaired skin or a wound being monitored or treated. During interview, RN #2 stated that nurses completed the skilled notes, that the computer prompted some of the documentation, and that the notes needed to be accurate because they were used to keep everyone informed on the resident’s progress; after reviewing the notes, he stated he could not say they were accurate.
Infection Control Practices Not Followed During Contact Precautions and Medication Administration
Penalty
Summary
The facility failed to implement infection control practices for two residents on contact precautions and for one resident during medication administration. For one resident with a physician order for Contact Isolation due to CRE, a CDC contact precautions sign was posted outside the room directing staff to clean hands and wear gloves and a gown before room entry. While the resident was lying in bed and the call light was ringing, a CNA entered the room and turned off the call light without donning a gown or gloves. The CNA later stated that staff should wear a gown and gloves when touching a resident or items in the room but could not explain why she did not do so in this instance. For another resident on contact precautions for a UTI, a sign outside the room instructed staff to wash hands and don gown and gloves before entering. A staff member entered the room without washing hands or donning gown or gloves, went to the bedside table to pick up the breakfast tray, then went to the roommate’s bedside, retrieved the roommate’s breakfast tray, and delivered both trays to dietary staff. The staff member sanitized hands only after leaving the room. Interviews with RN and CNA staff confirmed that gown and gloves were required for entry into a contact precautions room and that this applied regardless of the task being performed. During medication administration for a third resident, an RN prepared medications on a tray, sanitized hands, and donned gloves. After handling the medication cart and administering oral medications, the RN administered olopatadine eye drops and then gave an enoxaparin injection without changing gloves or sanitizing hands between tasks. An LPN stated that gloves should be changed and hands sanitized between oral medications, eye drops, and injections, and that this was basic nursing care to prevent contamination. The facility policy stated that gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them, with gloves changed when moving from a contaminated body site to a clean body site.
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What surveyors actually found near you
We read the 590 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Herndon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Oaks Health & Rehabilitation | 4.1 mi | ★★★★★ | 8 | 0 |
| Potomac Falls Health & Rehab Center | 7 mi | ★★★★★ | 0 | 0 |
| Fairfax Rehabilitation And Nursing Center | 7.6 mi | ★★★★★ | 7 | 0 |
| Ashby Ponds Inc | 7.6 mi | ★★★★★ | 0 | 0 |
| Johnson Cntr/falcons Landing | 8.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.