Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Vierra Falls Church during CMS and state inspections, most recent first.
A resident admitted with a lumbar burst fracture and a dehisced post-laminectomy back wound had wound care managed by contracted NPs. Initial assessments documented a full-thickness surgical wound without infection, and treatment orders were implemented, but staff did not document ongoing wound progression in progress notes. On a later visit, an NP documented that the wound had widened and that spinal surgical hardware was visible, yet still described the wound as stable and did not notify the attending physician or neurosurgeon, despite the care plan requiring reporting of abnormalities and signs of infection. The DON later stated that the exposed hardware should have been escalated, and a QIO review found that the surgeon did not appear to have been contacted when the hardware first became exposed. The resident was eventually sent from a scheduled surgical follow-up appointment to the hospital for a wound infection and started on antibiotics.
Two residents did not receive showers as scheduled and required by their care plans and facility policy. One resident, with moderate cognitive impairment and dependent on staff for bathing, was scheduled for twice-weekly showers but reported missing multiple consecutive showers, while CNA documentation showed conflicting entries for bed baths, showers, and even a tub bath despite the facility not having a tub. Another cognitively intact resident, needing partial to moderate assistance with bathing and care planned to receive a sponge bath if a full shower was not tolerated, had documentation of only one bathing event over an entire month, with no additional records produced upon request. The DON stated that all residents were to receive two showers per week per the CNA schedule and that CNAs were expected to document accurately, but the records did not support that this occurred.
A resident admitted with an unstable lumbar burst fracture and a surgical back wound had wound assessments documented in the EMR, including changes from full-thickness dehiscence to stability and later exposed surgical hardware. A contracted NP obtained wound photographs over several visits that showed initial improvement and later deterioration, with increased redness and wound width, but these images were never uploaded into the EMR. The DON confirmed the absence of the photographs in the clinical record, despite a facility policy requiring complete, accurate, and timely documentation of all assessments and observations to provide a clear picture of a resident’s progress.
A resident in an LTC facility was administered ten times the prescribed dose of IV Acyclovir due to a misunderstanding by an LPN. The LPN misinterpreted the pharmacist's instructions and failed to verify the medication order, resulting in the resident's hospitalization for acute kidney injury and acyclovir-induced nephrotoxicity. The resident, who had a history of encephalopathy and HSV encephalitis, was critically affected and later passed away after the family chose comfort measures.
A resident with a PICC line was not provided with proper infection control measures as an LPN administered IV medication without wearing a gown, despite orders for enhanced barrier precautions. Facility staff confirmed the protocol requires gown and glove use for such procedures, aligning with CDC guidelines to prevent MDRO transmission.
Failure to Escalate Change in Surgical Wound With Exposed Spinal Hardware
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a contracted wound NP recognized and escalated a significant change in a resident’s surgical back wound, which had exposed spinal hardware and possible infection. The resident was admitted with an unstable burst fracture of the first lumbar vertebra and had undergone a T10–L4 laminectomy, resulting in a surgical wound on the back that was dehisced on admission. The admission MDS showed the resident was cognitively intact, dependent on staff for all ADLs, and had a surgical wound. The care plan directed staff to monitor and document the wound’s location, size, and treatment, and to report abnormalities, failure to heal, and signs and symptoms of infection to the physician. Initial wound assessments by NP1 documented the wound as a full-thickness surgical dehiscence present on admission, with measurements recorded and no signs of infection noted. On a subsequent assessment, NP1 documented that the wound remained stable, with some slough present and moderate serosanguineous exudate, and the treatment plan was adjusted to cleansing with Vashe, application of Hydrofera Blue, and coverage with an ABD dressing three times per week. The Treatment Administration Record showed that clinical staff completed the ordered wound care, but there was a lack of progress notes documenting the wound’s appearance over time, which would have shown the progression or deterioration of the wound. On a later visit, NP2 assessed the wound and documented that it was stable, with measurements indicating a wider wound, 80% granulation tissue, 20% slough, and moderate serosanguineous exudate. NP2 also documented that there was exposed tissue including the spinal surgical hardware, and repeated this finding in a Skin and Wound Note. Despite this significant change, there was no indication that NP2 notified the resident’s physician or neurosurgeon, as required by the care plan. The DON stated that the exposure of spinal hardware should have been escalated and that the surgeon should have been alerted, and also noted that the former wound nurse (an LPN) should have questioned NP2 about the exposed hardware and did not, and that floor nurses should have documented the wound’s appearance after each dressing change. The resident had a follow-up appointment scheduled with the neurosurgeon, and NP2 documented that the resident was not seen again because of the upcoming appointment, with plans to follow up after that visit. At the neurosurgeon’s appointment, the resident was transferred to the emergency room due to a wound infection and was treated with antibiotics. A QIO review later noted that by the time NP2 documented visible surgical hardware, the surgeon did not appear to have been contacted sooner despite the new exposure of underlying hardware, and stated that such findings should prompt immediate contact with the surgeon and consideration of possible hospitalization. Interviews with NP1, the DON, the medical director’s NP, and the resident’s physician confirmed that the exposed spinal hardware and worsening wound should have triggered immediate notification of the surgeon, but this did not occur, resulting in a delay in further assessment and treatment.
Failure to Provide and Accurately Document Scheduled Showers for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and accurately document showers according to its own shower schedule and residents’ care plans for two residents. One resident was admitted with arthritis, muscle weakness, and lack of coordination, had a BIMS score of 10 indicating moderate cognitive impairment, and was care planned as dependent on staff for bathing/showering twice weekly and as necessary, with a preference to choose between a shower or sponge bath. The facility’s shower assignment schedule listed this resident to receive showers on Mondays and Thursdays on day shift. Despite this, the resident and a family member reported that the resident did not receive scheduled showers, missing multiple consecutive showers, and the resident stated on multiple occasions that no one came to offer or provide a shower. Record review for this resident showed inconsistencies and inaccuracies in CNA documentation of showers and baths. The Plan of Care response history indicated showers were due on specific dates, but CNAs documented some showers as non-applicable and entered multiple bathing events (bed baths, showers, and a tub bath) on various dates and times. One CNA later stated she had not provided the bed bath she documented and believed she had charted on the wrong resident. Another CNA documented a tub bath even though the facility did not have a tub bath, as confirmed by the ADON. These discrepancies showed that the documented bathing did not reliably reflect actual care provided and that the resident’s scheduled showers were not ensured according to the facility’s shower schedule and care plan. The second resident was admitted with muscle weakness, had a BIMS score of 15 indicating intact cognition, and required partial to moderate assistance with bathing. The care plan directed that the resident should receive a sponge bath if a full shower or bath could not be tolerated. Facility documentation for this resident showed only one shower/bath or sponge bath for an entire month, and when the surveyor requested all bathing/shower records for the resident’s stay, no additional records were produced. The DON stated that all residents were to receive two showers per week per the CNA book schedule and that CNAs were expected to follow the schedule and document correctly, but the records for this resident did not demonstrate that showers or sponge baths were provided as required by the facility’s policy and schedule.
Failure to Incorporate Wound Photographs Into Resident’s EMR
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation in the electronic medical record (EMR) for one resident with a surgical back wound. The resident was admitted with an unstable burst fracture of the first lumbar vertebra and had a surgical wound documented on the admission MDS, with a BIMS score of 15 indicating intact cognition and an upper body impairment. Wound Assessment Reports in the EMR documented a full-thickness surgical dehiscence on one date, a stable wound on a later date, and then a stable wound with exposed surgical hardware on a subsequent date. However, photographs taken of the wound by a contracted wound management nurse practitioner (NP1) on multiple visits, which visually demonstrated improvement between the first two assessments and a decline by the third, were not uploaded or incorporated into the resident’s EMR. During interviews, NP1 confirmed visits with the resident on two of the documented assessment dates and presented wound photographs showing the wound’s progression and later deterioration, including increased redness around the wound and increased wound width on the later date. NP1 stated she did not know why these images were not incorporated into the clinical record. The DON acknowledged that the photographs of the resident’s wound were not uploaded into the clinical record and stated that having such images would provide critical information on the wound’s status and healing. Review of the facility’s “Documentation in Medical Record” policy indicated that each resident’s medical record must contain an accurate representation of the resident’s experiences and enough information to provide a picture of the resident’s progress through complete, accurate, and timely documentation, and that licensed staff and interdisciplinary team members are to document all assessments and observations in the medical record.
Medication Error Leads to Resident Overdose
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medication, resulting in a significant medication error. A resident was prescribed 500 mg of intravenous Acyclovir every 12 hours for encephalitis. However, the staff administered ten times the prescribed dose, giving the resident 5 grams of Acyclovir instead of the intended 500 mg. This error was discovered after the resident exhibited symptoms of shortness of breath and altered mental status, leading to their transfer to the hospital for evaluation. The error occurred due to a misunderstanding by the LPN who administered the medication. The LPN misinterpreted the instructions from the pharmacist and believed that ten vials of Acyclovir, each containing 50 mg/mL, were needed to achieve the prescribed dose. The LPN failed to verify the medication order with the provider, nurse supervisor, or Director of Nursing, leading to the administration of an overdose. The pharmacist's instructions were misunderstood, and the LPN did not recognize the discrepancy between the vial's concentration and the prescribed dose. The resident, an 88-year-old female with a history of encephalopathy and HSV encephalitis, was critically affected by the overdose. She was admitted to the hospital with acute kidney injury and acyclovir-induced nephrotoxicity. The hospital records confirmed that the overdose led to the resident's altered mental status and respiratory distress. Despite efforts to manage the overdose, the resident's condition deteriorated, and the family eventually elected for comfort measures, leading to the resident's passing.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to implement proper infection control practices for a resident who required enhanced barrier precautions. Specifically, a licensed practical nurse (LPN) was observed administering intravenous (IV) medication to a resident with a peripherally inserted central catheter (PICC) line without wearing a gown, despite a physician's order for enhanced barrier precautions. The resident was receiving Unasyn for empyema, and a sign on the resident's door clearly indicated the need for enhanced barrier precautions, including the use of gloves and a gown during high-contact resident care activities. Interviews with facility staff confirmed that the protocol for residents with IV lines includes wearing gloves and a gown to protect the resident. The facility's policy and the Centers for Disease Control and Prevention guidelines both emphasize the importance of enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. The deficiency was brought to the attention of the facility's administrative staff, including the Administrator and the Director of Nursing.
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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 Falls Church
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arleigh Burke Pavilion | 1.1 mi | ★★★★★ | 0 | 0 |
| Cherrydale Health & Rehabilitation Center | 3.2 mi | ★★★★★ | 7 | 0 |
| The Jefferson | 3.2 mi | ★★★★★ | 43 | 3 |
| August Healthcare At Iliff | 3.3 mi | ★★★★★ | 4 | 0 |
| Sibley Mem Hosp Renaissance | 3.5 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.