Loudoun Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Loudoun Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689May 21, 2025

  2.a. For Resident #15 (R15), the facility staff failed to assess the resident to determine if the resident could safely spend time unsupervised on the courtyard patio and failed to provide supervision and a safe environment on the courtyard patio. R15 was unsupervised and fell on the courtyard patio. The resident sustained a head injury that required hospitalization, two staples for a laceration, and a C2 (second cervical) vertebral fracture. R15's diagnoses included but were not limited to congestive heart failure, muscle wasting and atrophy, paranoid personality disorder, auditory hallucinations, and dementia. R15's comprehensive care plan dated 7/19/23 failed to document information regarding the resident spending time outside on the courtyard patio. […]

• Immediate jeopardy, isolatedF805Dec 1, 2023

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to prepare and serve food and liquids to residents with orders for modified consistency diets for two of 41 residents in the survey sample, Residents #80 and #8. For Resident #8, the facility staff failed to serve pureed foods as ordered by the physician. For Resident #80, the facility staff served the incorrect food and fluid consistency which resulted in Resident #80 coughing and a nosebleed. The facility's deficient practice placed the resident at risk of infection, lack of oxygen to the brain, or death. This resulted in a determination of Immediate Jeopardy (IJ). […]

• Actual harm, isolatedF684Dec 5, 2024

  Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to administer an antibiotic for the treatment of a urinary tract infection. The resident missed six prescribed doses of Macrobid. The resident was sent out to the hospital three days later and admitted with septic shock from E. coli bacteremia/E.coli urinary tract infection, thus causing harm to one of two residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to administer six doses of the antibiotic, Macrobid (used to treat urinary tract infections) (1) prescribed to treat a urinary tract infection. […]

• No harm, potential for more than minimal, widespreadF941May 21, 2025

  Based on staff interview, and facility document review, the facility staff failed to ensure effective communication training was completed for five of five direct care staff employee reviews. The findings include: For CNA (certified nursing assistant) #10, CNA #11, RN (registered nurse) #2, LPN (licensed practical nurse) #11, and OSM (other staff member) #7 (the director of rehab), the facility staff failed to ensure effective communication training was completed. CNA #10 was hired on 11/1/23. CNA #11 was hired on 10/10/23. RN #2 was hired on 4/1/23. LPN #11 was hired on 4/1/23. OSM #7 was hired on 4/1/23. […]

• No harm, potential for more than minimal, widespreadF880Dec 1, 2023

  Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed failed to maintain an effective infection control tracking system; failed to maintain an effective infection control program for five of 41 residents in the survey sample, Residents #49 #24, #15, #86, #76 ; and failed to store linens in a sanitary manner, for one of one linen carts. The findings include: 1. The facility staff failed to maintain complete infection control tracking. The March, May, June 2023 tracking logs documented the number of the following infections: UTI (urinary tract infections) Pneumonia Wound Gastrointestinal Clostridium Difficile Cellulitis Osteomyelitis Surgical Other infections. […]