Deficiency Records for Lake Manassas Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Lake Manassas Health and Rehabilitation 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-14 | 2023-07-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-14 | 2023-07-11 | Y |
| Meet other general requirements. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| 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. | Health | 2022-07-14 | 2022-08-22 | N |
| 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 | 2022-07-14 | 2022-08-22 | 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 | 2022-07-14 | 2022-08-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-14 | 2022-08-22 | 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 | 2022-07-14 | 2022-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-14 | 2022-08-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-14 | 2022-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-14 | 2022-08-22 | 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 | 2022-07-14 | 2022-08-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-14 | 2022-08-22 | 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 | 2022-07-14 | 2022-08-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-14 | 2022-08-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-14 | 2022-08-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-14 | 2022-08-22 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-14 | 2022-08-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-27 | 2020-03-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-27 | 2020-03-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-27 | 2020-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-27 | 2020-03-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-27 | 2020-03-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-27 | 2020-03-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-27 | 2020-03-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-02-27 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-27 | 2020-03-16 | N |
| Dispose of garbage and refuse properly. | Health | 2020-02-27 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-03-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-08 | 2019-04-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-12-13 | 2019-01-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-13 | 2019-01-07 | 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 | 2018-12-13 | 2019-01-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-13 | 2019-01-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-13 | 2019-01-07 | 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 | 2018-12-13 | 2019-01-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-13 | 2019-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-13 | 2019-01-07 | N |
