The conditions of Loudoun Rehabilitation and Nursing in Leesburg, VA are atrocious.  They are very poorly managed with administrators rarely lasting more than 6 months.  They have run off many of the caring staff members and are short-staffed.  They often do not order diagnostic tests and blood work timely, and it can take days to get results that are needed stat.  They must have incentives not to call 911 when residents need it because they rarely seem to call 911 until it's too late, and residents and families hesitate to call 911 because the facility shames them for doing so.  Residents are not changed for hours at a time, ones who want to get up are often left in bed all day, and residents are sometimes left alone in the dining room well after the others have been put to bed.  Many residents don't receive a balanced and varied diet, and the dietician is not doing her job.  Meal tickets often don't agree to what's served.  Many residents aren't offered sufficient hydration.  Management doesn't know how many Hoyer slings they have, but there aren't enough for the number of residents who require them.  Hoyer slings are often not cleaned and are used again once the urine dries.  Residents are put into urine-soaked beds.  Call buttons for some residents are often unplugged so that residents can't ring for emergency assistance and can't watch TV.  They have been running out of supplies, such as diapers (especially 3X size which means they put residents into diapers that are too small), gloves, masks, soap, etc. which has had a direct correlation to an increase in infections that have resulted in sepsis and death.  The Resident Council was taken over by management despite protests of residents and families. The facility can't effectively control the heating, air conditioning, and humidity levels.  If you join and read the Loudoun Aging Parents site on FaceBook, you'll see that our community is well aware of the neglect and abuse that goes on there, and some of the positive comments have been from staff and management at this or a related facility without any acknowledgement that it's a biased comment.  Yet, when OLC finally came out a couple of months ago after over a year of not showing up despite numerous and serious complaints being submitted, they only chose to investigate one death.  They gave this nursing home a "deficiency free survey," which the facility celebrated and bragged about on their Facebook site.  Did the inspectors actively seek out staff, visitors, etc. who witnessed the decline of the deceased?  Did they verify in the system if the medical records/notes had been updated after the fact to make it look like care was given when it wasn't?  Something seems very wrong as to why the inspector could come to this conclusion based on eye witness accounts.  Because retaliation is very real, why don't the inspectors change how they audit to pay more attention to anonymous complaints?  Why aren't the inspectors looking for patterns and trends related to the complaints, especially when suspicious deaths have occurred?  Why don't inspectors walk randomly into residents' rooms and take a detailed look for the conditions related to the above complaints?  As soon as an inspector shows up, additional staff is called in and the facility sweeps through the rooms to do their best to ensure they are in compliance so why don't inspectors stop this from happening?  There have been allegations of serious fraud so why aren't the financials being investigated?  Why aren't the staff protected when they take their mandated reporter duties seriously?  When residents are sent to the hospital, why aren't the hospitals taking their mandated reporter duties seriously, and if they are, then why does it take over a year for inspectors to show up only to look at 1 incident and find nothing?  In May 2025, OLC issued many pages of violations for this facility, yet they subsequently cleared all of them even though many of the same conditions were still occurring so the re-audit process failed.  Your entire inspection process needs to be revamped.  Why do the Ombudmen in Virginia have so little power to get nursing homes to change their bad behavior and no ability to assess fines since they are at the facilities much more often than OLC?  Unless there are serious financial consequences to the gross neglect and lack of care, changes will never occur.