Safety Report: Loudoun Rehabilitation and Nursing Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
2Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
17Requirements cited on more than one inspection
L
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies · Tag F805
Citations by topic
6Abuse, neglect & exploitation
4Infection control
5Medications & pharmacy
1Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (26) than in the cycle before (42).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 5 | May 21, 2025; December 5, 2024; December 1, 2023; April 26, 2022; March 21, 2019 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 4 | May 21, 2025; December 5, 2024; December 1, 2023; March 21, 2019 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 4 | May 21, 2025; December 1, 2023; April 26, 2022; March 21, 2019 |
| Provide and implement an infection prevention and control program. (F880) | 3 | May 21, 2025; December 1, 2023; March 21, 2019 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 3 | May 21, 2025; April 26, 2022; March 21, 2019 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 3 | December 1, 2023; April 26, 2022; March 21, 2019 |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (F622) | 3 | December 1, 2023; April 26, 2022; March 21, 2019 |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (F947) | 2 | May 21, 2025; April 26, 2022 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | May 21, 2025; April 26, 2022 |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (F805) | 2 | May 21, 2025; December 1, 2023 |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. (F745) | 2 | May 21, 2025; December 1, 2023 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 2 | May 21, 2025; December 1, 2023 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | May 21, 2025; December 1, 2023 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 2 | May 21, 2025; December 1, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | December 1, 2023; April 26, 2022 |
| Ensure each resident receives an accurate assessment. (F641) | 2 | December 1, 2023; April 26, 2022 |
| Keep residents' personal and medical records private and confidential. (F583) | 2 | December 1, 2023; March 21, 2019 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| May 21, 2025 | Fine | $27,373 |
| December 5, 2024 | Fine | $29,370 |
| December 1, 2023 | Payment Denial | Payment denial for 110 days, starting March 1, 2024 |
| December 1, 2023 | Fine | $66,846 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
May 21, 2025 — 28 citations (includes serious) · complaint investigation
L
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Widespread · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 17, 2025
F
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F941 · complaint · corrected June 17, 2025
E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F949 · complaint · corrected June 17, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected July 25, 2025
E
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F730 · complaint · corrected June 17, 2025
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected June 17, 2025
E
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F606 · complaint · corrected June 17, 2025
E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F580 · complaint · corrected June 17, 2025
D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F947 · complaint · corrected June 17, 2025
D
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F944 · complaint · corrected June 17, 2025
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected June 17, 2025
D
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F836 · complaint · corrected June 17, 2025
D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · complaint · corrected June 17, 2025
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · complaint · corrected June 17, 2025
D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F745 · complaint · corrected June 17, 2025
D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F725 · complaint · corrected June 17, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · complaint · corrected June 17, 2025
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected June 17, 2025
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected June 17, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected June 17, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected June 17, 2025
D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F628 · complaint · corrected June 17, 2025
D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F627 · complaint · corrected June 17, 2025
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected June 17, 2025
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected June 17, 2025
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected June 17, 2025
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected June 17, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected June 17, 2025
December 5, 2024 — 2 citations (includes serious) · complaint investigation
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected January 7, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected January 7, 2025
December 1, 2023 — 26 citations (includes serious)
J
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Immediate jeopardy to resident health or safety · Isolated · Nutrition and Dietary Deficiencies · F805 · complaint · corrected January 15, 2024
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · complaint · corrected January 15, 2024
E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F909 · corrected January 15, 2024
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected February 16, 2024
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected January 15, 2024
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected February 16, 2024
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F883 · complaint · corrected January 15, 2024
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected January 15, 2024
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected January 15, 2024
D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F745 · corrected January 15, 2024
D
Provide care or services that was trauma informed and/or culturally competent.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F699 · corrected January 15, 2024
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected January 15, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected February 16, 2024
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · complaint · corrected January 15, 2024
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected January 15, 2024
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected January 15, 2024
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected January 15, 2024
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected January 15, 2024
D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F622 · corrected January 15, 2024
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected January 15, 2024
D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected January 15, 2024
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected January 15, 2024
D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F582 · corrected January 15, 2024
D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected January 15, 2024
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · corrected February 16, 2024
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected February 16, 2024
April 26, 2022 — 12 citations
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected June 6, 2022
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · corrected June 6, 2022
D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F947 · corrected June 6, 2022
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected June 6, 2022
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected June 6, 2022
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected June 6, 2022
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected June 6, 2022
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected June 6, 2022
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected June 6, 2022
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected June 6, 2022
D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F622 · corrected June 6, 2022
B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
No actual harm, potential for minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F640 · corrected June 6, 2022
March 21, 2019 — 8 citations
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected May 1, 2019
E
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F622 · corrected May 1, 2019
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected May 1, 2019
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected May 1, 2019
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected May 1, 2019
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected May 1, 2019
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected May 1, 2019
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected May 1, 2019
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare