Dulles Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Dulles Health & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Mar 26, 2026

  Based on observation, resident representative interview, staff interview, clinical record interview, and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for 10 out of 54 residents in the survey sample, Residents #185, #17, #90, #161, #134, #6, #8, #10, #132 and #1. The findings include:1. For Resident #185 (R185), the facility staff failed to implement the comprehensive care plan to provide incontinence care/toileting assistance on night shift 6/28/2024 and 6/30/2024. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 6/22/2024, the resident was assessed as being frequently incontinent of bowel and bladder and being dependent on staff for toileting. […]

• No harm, potential for more than minimal, patternF757Mar 26, 2026

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor side effects to prevent unnecessary medication administration for four of 54 residents in the survey sample, Residents #2, #8, #10, and #1.The findings include:1. For Resident #2 (R2), the facility staff failed to monitor for side effects of Enoxaparin (1). A review of R2's clinical record revealed the following order dated 2/12/26: Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (milligram per milliliter) Inject 1 ml.every 12 hours. A review of R2's February and March 2026 MARs (medication administration record) revealed she had received the medication as ordered each day. […]

• No harm, potential for more than minimal, patternF812Mar 26, 2026

  Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to serve food in a safe and sanitary manner for one of one kitchen.The findings include:On 3/23/2026 at approximately 11:48 AM, an observation was made of the facility kitchen with the food service director. Observation of the dry good storage area revealed a 46 fluid ounce carton of thickened apple juice which documented Use by [DATE]. Observation of the kitchen area revealed a wire shelving rack with 6 stacked pans which the director stated were meatloaf pans and were clean and available for use. Two of the pans were observed to have visible debris adhering to the inside of the pans. […]

• No harm, potential for more than minimal, patternF585Dec 7, 2022

  Based on Resident interview, facility staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to respond to, and take measures to resolve, concerns affecting residents on 4 of 4 nursing units. The findings included: The facility staff failed to respond in an effective manner to ensure resolution of ongoing concerns regarding the lack of call bell responses. On 12/5/22, in the course of a complaint investigation, a review of grievance forms from multiple residents revealed concerns reported to the facility staff of ongoing issues of facility staff not responding to call lights. The grievance forms documented the following: i. […]

• No harm, potential for more than minimal, patternF607Dec 7, 2022

  Based on staff interview, facility documentation review and in the course of a complaint investigation, the facility staff failed to implement their abuse policy for 7 Residents (Resident #15, 12, 2, 11, 16, 13, and 14), in a survey sample of 25 Residents. The findings included: 1. For Residents #15, 11, 16, 13, 14, and 12, the facility staff failed to implement their abuse policy with regards to conducting investigations in response to allegations of abuse. On 12/5/22, during the course of a complaint investigation it was determined that multiple Residents had reported allegations of abuse to the facility staff, and the facility staff failed to conduct an investigation regarding the allegations. i. […]