Loudoun Rehabilitation And Nursing Center
For profit - Limited Liability company · 235 Old Waterford Road, Northwest, Leesburg, VA 20176 · See home’s Medicare page
4.14
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.8
31.1%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 48.7%
100
Certified beds
Qualifying beds in the certified provider or supplier facility.
92
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Loudoun Va Opco Holdco Llc (100%)
Indirect owners
Loudon920 Llc (37%)
Pc8 Capital Group Llc (26%)
Sj Healthcare Capital Llc (26%)
Pc8 Capital Group Llc (26%)
Sj Healthcare Capital Llc (26%)
Managerial control
Pamela Clark since Jul, 2025
Simon Stern since Apr, 2023
Simon Stern since Apr, 2023
Managing employee(s)
No information available
Inspection Reports
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
76
total deficiencies
4
infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Many people affected
Seriousness
Administration Deficiency — F0941
Failure to:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nursing and Physician Services Deficiency — F0730
Failure to:
Observe each nurse aide's job performance and give regular training.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0580
Failure to:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0606
Failure to:
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Administration Deficiency — F0949
Failure to:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0695
Failure to:
Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nursing and Physician Services Deficiency — F0725
Failure to:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0745
Failure to:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0761
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0805
Failure to:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0836
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0842
Failure to:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0944
Failure to:
Conduct mandatory training, for all staff, on the facility's Quality Assurance and Performance Improvement Program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nursing and Physician Services Deficiency — F0947
Failure to:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0690
Failure to:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to:
Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0627
Failure to:
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0628
Failure to:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0805
Failure to:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Environmental Deficiency — F0909
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0641
Failure to:
Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0655
Failure to:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0697
Failure to:
Provide safe, appropriate pain management for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0699
Failure to:
Provide care or services that was trauma informed and/or culturally competent.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0745
Failure to:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0755
Failure to:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0759
Failure to:
Ensure medication error rates are not 5 percent or greater.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0658
Failure to:
Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0676
Failure to:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0554
Failure to:
Allow residents to self-administer drugs if determined clinically appropriate.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0883
Failure to:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0578
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0582
Failure to:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0583
Failure to:
Keep residents' personal and medical records private and confidential.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0584
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0622
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0641
Failure to:
Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0658
Failure to:
Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0695
Failure to:
Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0756
Failure to:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0758
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0842
Failure to:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nursing and Physician Services Deficiency — F0947
Failure to:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0622
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0640
Failure to:
Encode each resident's assessment data and transmit these data to the State within 7 days of assessment.
Severity
No actual harm, with potential for minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0622
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0695
Failure to:
Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0658
Failure to:
Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0583
Failure to:
Keep residents' personal and medical records private and confidential.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Penalties
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
$102K
total fines
1
payment suspension