A list of the most recent deficiencies for Dulles Health and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-11-15 | 2023-12-26 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-15 | 2023-12-26 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-07 | 2023-01-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-07 | 2023-01-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-07 | 2023-01-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-07 | 2023-01-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-10 | 2022-09-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-08-10 | 2022-09-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-10 | 2022-09-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-22 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-04 | 2021-09-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-08-04 | 2021-09-22 | N |
| 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. | Health | 2021-08-04 | 2021-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-09-22 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-05 | 2019-02-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-09-27 | 2018-11-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-27 | 2018-11-07 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-09-27 | 2018-11-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-27 | 2018-11-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-27 | 2018-11-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-27 | 2018-11-07 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-27 | 2018-11-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-27 | 2018-11-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-09-27 | 2018-11-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-27 | 2018-11-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-09-27 | 2018-11-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-27 | 2018-11-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-27 | 2018-11-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-27 | 2018-11-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-27 | 2018-11-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-09-27 | 2018-11-07 | N |
| 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. | Health | 2018-09-27 | 2018-11-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-27 | 2018-11-07 | N |
| Use approved construction type or materials. | Fire Safety | 2017-08-21 | 2017-11-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-08-21 | 2017-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-21 | 2017-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-21 | 2017-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-21 | 2017-11-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-07-27 | 2017-09-05 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-07-27 | 2017-09-05 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-07-27 | 2017-09-05 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-07-27 | 2017-09-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-07-27 | 2017-09-05 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-27 | 2017-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-27 | 2017-09-05 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2017-07-27 | 2017-09-05 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-27 | 2017-09-05 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-07-27 | 2017-09-05 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-07-27 | 2017-09-05 | N |
