A list of the most recent deficiencies for Fredericksburg Health and Rehab. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-17 | 2024-02-16 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-10-26 | 2023-11-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-26 | 2023-11-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-21 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-26 | 2023-11-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-29 | 2023-09-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-26 | 2023-08-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-26 | 2023-08-24 | Y |
| Provide appropriate foot care. | Health | 2023-07-26 | 2023-08-24 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-07-26 | 2023-08-24 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-26 | 2023-08-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-26 | 2023-08-24 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-26 | 2023-08-24 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-07-26 | 2023-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-26 | 2022-12-19 | 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 | 2022-09-01 | 2022-10-21 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-09-01 | 2022-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-01 | 2022-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-01 | 2022-10-21 | N |
| 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. | Health | 2022-08-31 | 2022-09-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-31 | 2022-09-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-31 | 2022-09-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-31 | 2022-09-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-31 | 2022-09-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-31 | 2022-09-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-31 | 2022-09-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-31 | 2022-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-31 | 2022-09-28 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-08-31 | 2022-09-28 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-08-31 | 2022-09-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-31 | 2022-09-28 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-31 | 2022-09-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-19 | 2021-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-19 | 2021-06-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-05-19 | 2021-06-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-16 | 2021-05-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-16 | 2021-05-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-04-16 | 2021-05-18 | N |
| Post nurse staffing information every day. | Health | 2021-04-16 | 2021-05-18 | 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 | 2021-04-16 | 2021-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-16 | 2021-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-16 | 2021-05-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-16 | 2021-05-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-16 | 2021-05-18 | 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 | 2019-11-20 | 2020-01-22 | 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 | 2019-11-20 | 2020-01-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-20 | 2020-01-22 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-11-20 | 2020-01-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-20 | 2020-01-22 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2019-11-20 | 2020-01-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-20 | 2020-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-20 | 2020-01-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-26 | 2019-08-25 | N |
| 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. | Health | 2019-07-26 | 2019-08-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-26 | 2019-08-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-26 | 2019-08-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-26 | 2019-08-25 | N |
| 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. | Health | 2019-07-26 | 2019-08-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-26 | 2019-08-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-26 | 2019-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-26 | 2019-08-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-26 | 2019-08-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-26 | 2019-08-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-26 | 2019-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-26 | 2019-08-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-26 | 2019-08-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-26 | 2019-08-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-07-26 | 2019-08-25 | 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 | 2019-07-26 | 2019-08-25 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-07-26 | 2019-08-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-07-26 | 2019-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-26 | 2019-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-26 | 2019-08-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-26 | 2019-08-25 | N |
