August Healthcare at Leewood: Abuse Reporting Failure - VA
Nobody called the state.
That was March 20, 2025. Inspectors from the state survey agency didn't learn about it until they showed up at August Healthcare at Leewood more than thirteen months later, during a complaint inspection on April 29 and 30, 2026. When they asked the facility's chief executive officer directly whether the incident had been reported, the CEO confirmed it had not.
The resident, identified in inspection records only as Resident 94, had been admitted to the facility with diagnoses that included altered mental status. That detail matters. Residents with altered mental status are among the most vulnerable to abuse and among the least able to report it themselves. They depend on the people caring for them, and on the systems those caregivers work within, to make sure that when something goes wrong, someone with authority outside the building finds out.
At August Healthcare at Leewood, that system failed completely.
The incident was documented internally. A registered nurse named RN1 filed an incident report at 9:45 PM on March 20, 2025, writing that a certified nursing aide, identified as CNA2, had informed her that Resident 94 "developed discoloration of bilateral wrist during ADLs care when changing resident clothes" and that "the resident was resisting care." According to RN1's account, the resident's wrists struck a wheelchair during the transfer. Two and a half hours later, at 11:35 PM, RN1 filed a separate nurse's note in the electronic medical record confirming the same findings: discoloration and swelling to both wrists, ice bags applied, physician notified, x-ray ordered to rule out fracture.
The paper trail was there. The injury was documented. The physician was looped in.
The state was not.
When inspectors interviewed the facility's administrator on April 29, 2026, she told them she had been serving as the Director of Nursing at the time of the March 2025 incident. She knew the two-hour reporting requirement. She confirmed the allegation had not been reported. Her explanation: the facility had determined on its own that what happened to Resident 94 was neither an injury of unknown origin nor abuse, and therefore decided no report was required.
That reasoning is precisely the kind of internal determination that external oversight is designed to check. A resident with cognitive impairment sustains bilateral wrist injuries during a care encounter in which she was resisting. The question of whether that constitutes an injury of unknown origin, or whether it rises to the threshold of an abuse allegation, is not a call the facility gets to make in isolation and then file away. The entire architecture of mandatory reporting exists because facilities cannot be trusted to investigate themselves and reach conclusions that protect residents rather than the institution.
The facility's own abuse policy, revised in November 2021, stated that reporting to the administrator, the state agency, adult protective services, and other required authorities must happen "immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury." The swelling, the discoloration, the x-ray ordered to rule out fractures — the facility's own nurses documented findings serious enough to summon a physician in the middle of the night. Then the same facility decided none of that warranted a call to the state.
The inspection deficiency was cited at a level of minimal harm or potential for actual harm, which is the lowest tier on the federal harm scale. That classification reflects what inspectors could document, not necessarily what the full consequences of the reporting failure were. Once an incident goes unreported, the external review that might have caught something the facility missed never happens. No state investigator examined CNA2's employment history. No outside authority reviewed whether Resident 94's injury was consistent with the explanation given. The facility's internal conclusion, that this was simply an accident during a difficult care moment, was never tested.
Inspectors noted the deficiency cross-referenced two separate federal tags: one governing abuse prohibition policies and one governing the obligation to investigate and report. The fact that both tags were triggered suggests inspectors found not just a reporting lapse but a systemic question about how the facility handled the allegation once it was made internally.
August Healthcare at Leewood is located at 7120 Braddock Road in Annandale, a suburb of Washington, D.C. in Fairfax County. The inspection was a complaint survey, meaning someone — a resident, a family member, a staff member, or another party — had contacted authorities with concerns before inspectors arrived. The inspection report does not identify the nature of the original complaint or whether it was related to Resident 94's case.
What the report does establish is that when inspectors sat down with the CEO and the administrator on the afternoon of April 29, 2026, and asked whether the March 2025 incident had been reported to state authorities, neither of them disputed the answer. The CEO said it had not been reported. The administrator confirmed it had not been reported. There was no confusion about what had happened. There was no claim that a report had been filed and lost. The facility had made a judgment call thirteen months earlier, decided it didn't need to tell anyone, and held to that position when federal inspectors came asking.
Resident 94, in the meantime, had bilateral wrist injuries that were serious enough to require physician notification and x-ray imaging, documented in detail by nursing staff who clearly understood something had gone wrong during a care encounter with a cognitively impaired resident who was unable to cooperate. Whether those injuries healed without complication, whether Resident 94 remained at the facility, whether CNA2 continued working there — none of that appears in the inspection record.
The ice bags were applied. The x-ray was ordered. The state was never called.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for August Healthcare At Leewood from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
AUGUST HEALTHCARE AT LEEWOOD in ANNANDALE, VA was cited for abuse-related violations during a health inspection on April 30, 2026.
When they asked the facility's chief executive officer directly whether the incident had been reported, the CEO confirmed it had not.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.